• v . .'-'■■'.::,■ ■■:';■ \ v /-.:,; .; . 




Class _JZ2/o/ 
Book 



<r«g& 



Copyright^ . 



COPYRIGHT DEPOSIT. 



A PRACTICAL TREATISE 



ON 



FRACTURES AND DISLOCATIONS. 



BY 

LEWIS A. STIMSON, B.A., M.D V LL.D. (Yalen), 

PROFESSOR OF SURGERY IN CORNELL UNIVERSITY MEDICAL COLLEGE, NEW YORK J SURGEON TO 

THE NEW YORK AND HUDSON ST. HOSPITALS J CONSULTING SURGEON TO BELLEVUE, 

ST. JOHNS, AND CHRIST HOSPITALS; CORRESPONDING MEMBER OF THE 

SOCIETE DE CHIRURGIE OF PARIS. 



SIXTH EDITION, REVISED AND ENLARGED. 



WITH 361 ILLUSTRATIONS AND 65 PLATES IN MONOTINT. 




LEA & FEBIGER, 

NEW YORK AND PHILADELPHIA. 
1910 



o x 



«> „<&& 



Co 



Entered according to Act of Congress, in the year 1910, by 

LEA & FEBIGER, 

In the Office of the Librarian of Congress. All rights reserved. 



©B.A2 



5960f> 



PREFACE TO THE SIXTH EDITION. 



The additions to this edition largely represent the results of 
further study of the injuries of the small bones of the carpus and tarsus 
and include a new subhead, the midcarpal fracture-dislocations, the 
recognition of which has come mainly through investigations stimulated 
and aided by x-ray examinations. There is reason to think that the 
knowledge now gained covers all the typical lesions. 

Sections have also been added on fractures of the floor of the 
acetabulum and of the internal epicondyle of the femur and on back- 
ward dislocation of the lower jaw. Other additions of importance 
relate to treatment. 

Reproductions of seventeen skiagrams have been added in the 
plates and a number of new cuts have been added or substituted. 

Lewis A. Stimson. 

277 Lexington Avenue, N. Y., 
1910. 



CONTENTS. 



FRACTURES. 



CHAPTER I. 

INTRODUCTION. 

PAGE. 

Definitions, statistics, influences of sex, age, and season 19 

CHAPTER II. 

PATHOLOGY. 

A. The bone ; varieties of fracture 22 

1. Incomplete fractures 23 

(a) Fissures ' • 23 

(b) True incomplete, green-stick ; infraction 24 

(c) Depressions • • . . . 24 

(d) Separation of a splinter or apophysis 24 

2. Complete fractures ; subdivided according to 25 

(a) Direction and character of the line of fracture 25 

(b) The seat of fracture 29 

Separation of epiphysis 29 

(c) Intra-articular 31 

3. Multiple fractures . 31 

4. Compound fractures 32 

5. Gunshot fractures 33 

Displacements 36 

B. The soft parts 37 

CHAPTER III. 

ETIOLOGY. 

Predisposing causes 39 

External, normal, interstitial atrophy 39 

Inherited liability 40 

Determining causes 40 

External violence, direct or indirect 40 

Muscular action . . , 41 

Spontaneous and pathological fractures 45 

General diseases 45 

Diseases of nerve centres 46 

Rachitis, syphilis, rheumatism 47 

Cancer and sarcoma 48 

Cysts, osteomyelitis 49 

Intra-uterine, and during delivery 49 

CHAPTER IV. 

EARLY SYMPTOMS AND DIAGNOSIS. 

Objective signs 51 

Deformity (normal asymmetry) 51 

Abnormal mobility 52 

Crepitus 53 

Roentgen rays 54 

Subjective or rational symptoms 55 

Loss of function ; pain 

History 55 



VI CONTENTS. 

CHAPTER V. 

REPAIR OF FRACTURES AND CLINICAL COURSE. 

PAGE 

Anatonio-pathological processes 57 

The callus 57 

In compound fracture •"•"•* 61 

In short and flat bones g2 

At the epiphyseal line . 53 

Clinical course g4 

CHAPTEB VI. 

COMPLICATIONS AND REMOTE CONSEQUENCES. 

Early local complications 68 

Skin. Bloodvessels 68, 69 

Gangrene. Degeneration of muscles 70 

Suppuration 71 

Early general complications 71 

Septicaemia 71 

Fat embolism 72 

Delirium tremens, tetanus, pneumonia 73 

Late local complications 74 

Excessive or painful callus 74 

Development of a tumor 75 

Injury of a nerve 75 

Weakness of callus 76 

Arrest or exaggeration of growth 77 

Stiflhess of the joints 77 

Atrophy. Thrombosis and embolism 78 

Arteries 79 

CHAPTER VII. 

TREATMENT. 

Reduction 81 

Retention 87 

Temporary and removable dressings 89 

Wooden splints 89 

Metal splints , 90 

Volkmann's splint 90 

Anterior suspended splints 92 

Moulded splints 93 

Permanent or final dressings 95 

Encasement in plaster 95 

Traction, Buck's extension 97 

Hodgen's splint, long side splint 99 

Combined suspension and traction 100 

Vertical suspension. Double inclined plane 101 

Direct fixation .... • 103 

Massage 105 

Ambulatory treatment ■. 106 

Management of the joints 107 

Compound fractures 109 

By indirect violence 110 

By direct violence 110 

Gunshot fractures 112 

Amputation 112 

Compound articular fractures .... 113 

General treatment 114 

CHAPTER VIII. 

DELAYED UNION, FAILURE OF UNION, FAULTY UNION. 

Delaved union ; failure of union 115 

Pathology 116 

Etiology 116 



CONTENTS. VII 

PAGE 

Delayed union : symptoms 118 

Treatment 119 

Faulty or vicious union 121 

Treatment 122 

CHAPTER IX. 

GENERAL PROGNOSIS 124 

CHAPTER X. 

FRACTURES OF THE SKULL. 

Mechanism and pathology 128 

Exceptional forms 133 

Internal table 134 

Injuries of brain 135 

Pathological and reparative processes 136 

Symptoms, diagnosis, and treatment 137 

Circumscribed fractures of the vault 138 

Fissured fractures with generalized brain injury 140 

Internal table 143 

Rupture of the middle meningeal artery 143 

Perforating fractures of the base 144 

Summary 145 

CHAPTER XI. 

FRACTURES OF THE VERTEBRAE. 

Pathology 148 

Heematomyelia 151 

Etiology 151 

Symptoms and diagnosis 152 

Atlas and axis 153 

Lower five cervical and first two dorsal 155 

Lower dorsal and first two lumbar 157 

Lower three lumbar 158 

Course and termination 158 

Treatment 161 

CHAPTER XII. 

FRACTURES OF THE BONES OF THE FACE. 

1. Nose 165 

2. Malar bone and zygoma 167 

3. Superior maxilla . • • ■ 169 

4. Inferior maxilla 171 

CHAPTER XIII. 

FRACTURES OF THE HYOID BONE 180 

CHAPTER XIV. 

FRACTURES OF THE LARYNX AND TRACHEA 182 

CHAPTER XV. 

FRACTURES OF THE STERNUM 184 

CHAPTER XV I. 

FRACTURES OF THE RIBS AND THEIR CARTILAGES 190 

The ribs 190 

The costal cartilages . 195 



vi li COS TEXTS. 

CHAPTER XVII. 

FRACTURES OF THE CLAVICLE. PAGE 

Pathology 199 

1. Middle third 200 

2. Outer third 201 

3. Inner third 202 

Multiple fractures. Complications 203 

Etiology 205 

Symptoms and course 206 

Simultaneous fractures of both clavicles 208 

Treatment 209 

CHAPTER XVIII. 

FRACTURES OF THE SCAPULA. 

1. Of the body of the scapula 215 

2. Of the inferior angle 217 

3. Of the upper angle 218 

4. Of the spine . 218 

5. Of the acromion 218 

6. Of the coracoid process 220 

7. Of the neck 221 

8. Of the glenoid cavity 223 

CHAPTER XIX. 

FRACTURES OF THE HUMERUS. 

994- 

1. Fractures of the upper end of the humerus tzz 

A. Fractures of the head j~*l 

B. Fractures of the anatomical neck and fracture through the tuberosities . . tt^ 

C. Fractures of the tuberosities 2-9 

D. Separation of the epiphysis 232 

E. Fracture of the surgical neck = ~~ 

Symptoms 239 

Diagnosis 240 

Prognosis, treatment 241 

2. Fractures of the shaft of the humerus 245 

3. Fractures of the lower end of the humerus . 249 

A. Fractures above the condyles — supracondyloid 251 

B. Fractures of the internal epicondyle 257 

C. Fractures of the external epicondyle 258 

D. Fractures of the internal condyle 259 

E. Fractures of the external condyle 261 

F. Intercondyloid, T-shaped or Y-shaped fractures 264 

G. Separation of the epiphysis 265 

H. Fractures of the articular process 266 

Of the capitellum 267 

Of the trochlea -269 

Diagnosis 269 

Treatment 270 

CHAPTER XX. 

FRACTURES OF THE BONES OF THE FOREARM. 

1. In the vicinity of the elbow-joint 271 

A. Olecranon 277 

B. Coronoid process % . . 278 

C. Of the head of the radius 280 

D. Of the neck of the radius 283 

2. Fractures of the shaft 284 

A. Fractures of the shafts of both bones • 284 

B. Of the shaft of the ulna 290 

C. Of the shaft of the radius . _ 292 

3. Fractures in the vicinity of the wrist 293 



CONTENTS. ix. 

PAGE 

A. Fractures of the radius. Colles's fracture 293 

Cause «g 

Symptoms oL,u 

Treatment 300 

B. Fractures at the wrist other than Colles's 302 

CHAPTER XXI. 

FRACTURES OF THE CARPUS AND HAND. 

1. Fractures of the carpal bones 30^ 

2. Fractures of the metacarpal bones £jU 

3. Fractures of the phalanges 312 

CHAPTER XXII. 

FRACTURES OF THE PELVIS. 

1. Fractures of the ring of the pelvis 314 

Separation of the symphysis pubis 315 

Separation in front and behind ... 316 

Separation of the sacro-iliac synchondrosis 316 

Separation of all three joints 316 

Fracture of the pubic portion of the pelvic ring 317 

Fracture of the lateral portion 317 

Course, diagnosis, treatment 319 

2. Radiating fracture and fracture of the floor of the acetabulum 320 

3. Transverse fracture of the sacrum 322 

4. Fracture of the coccyx 323 

5. Fracture of the ilium 324 

6. Fracture of the ischium 325 

7. Fracture of the pubis 326 

8. Fracture of the rim of the acetabulum 326 

CHAPTER XXIII. 

FRACTURES OF THE FEMUR. 

1. Fractures at the upper end of the femur 329 

A. Fractures of the head of the femur .... 329 

B. Fracture of the neck of the femur 329 

Causes 333 

Pathology 334 

(a) Fractures through the neck 334 

(6) Separation of the epiphysis 335 

(c) Fractures at the base of the neck 337 

Repair 342 

Symptoms 346 

Diagnosis 350 

Prognosis 352 

Treatment 354 

C. Fractures through the trochanter and neck 360 

D. Fracture of the great trochanter 361 

E. Fracture of the trochanter minor 861 

2. Fractures of the shaft of the femur 362 

3. Fractures of the lower end of the femur 371 

A. Intercondyloid fractures 371 

B. Separation of the epiphysis 374 

C. Fracture of either condyle : 376 

D. Fracture of the internal epicondyle . 37 S 

CHAPTER XXIY. 

FRACTURES OF THE PATELLA. 

Cause 379 

Pathology 3^0 

Symptoms . ggg 



x CONTEXTS. 

PAGE 

Treatment 385 

Non-operative 3gg 

Operative 390 

For relief of disability 393 

For refracture 394 

CHAPTER XXV. 

FRACTURES OF THE BONES OF THE LEG. 

1. Fractures of the upper end 395 

Separation of the epiphysis 397 

Avulsion of the spine of the tibia .- 397 

Avulsion of the tubercle of the tibia 398 

2. Fractures of the shaft 399 

3. Fractures at the lower end of the leg 403 

A. Comminuted fracture of the tibia 403 

B. Supramalleolar fracture 404 

C. Separation of the epiphysis of the tibia 405 

D. Fractures by e.version and abduction, Pott's 405 

E. Fractures of the malleoli by inversion 413 

F. Of the posterior portion of articular surface 414 

G. Of the anterior portion of the articular surface 416 

4. Fractures of the fibula 416 

A. Of the upper end 416 

B. Of the shaft 417 

C. Separation of lower epiphysis 4 17 

CHAPTER XXVI. 

FRACTURES OF THE BONES OF THE FOOT. 

1. Of the astragalus 418 

Of processus posticus 419 

2. Of the calcaneum 419 

Of the sustentaculum , 420 

By muscular action 421 

3. Of the scaphoid 422 

4. Of the cuboid 423 

5. Fractures of the metatarsal bones 423 

6. Fractures of the phalanges 424 



DISLOCATIONS. 



CHAPTER XXVII. 

GENERALITIES. 

Definitions - 427 

Statistics 429 



CHAPTER XXVIII. 

ETIOLOGY AND MECHANISM. 

A. Predisposing causes 432 

B. Immediate or determining causes * ' 433 

Recurrent or habitual dislocations 434 



CONTENTS. xi 
CHAPTER XXIX. 

PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS ; COMPLICATIONS ; PROCESS OF 

REPAIR AFTER REDUCTION. PAGE 

Pathological anatomy 436 

Complications 437 

Bones 437 

Bloodvessels 438 

Nerves 440 

Viscera 443 

Soft parts and integument 443 

Repair 444 

CHAPTER XXX. 

PATHOLOGY OF UNREDUCED (ANCIENT) DISLOCATIONS 447 

CHAPTER XXXI. 

SYMPTOMS AND DIAGNOSIS. 

Objective signs 452 

Deformity ♦ 452 

Loss of mobility 454 

Crepitus 455 

Subjective symptoms 455 

Pain 455 

Loss of function ; history 455 

CHAPTER XXXII. 

COURSE AND PROGNOSIS 457 

CHAPTER XXXIII. 

TREATMENT. 

Spontaneous reduction 459 

Obstacles to reduction 459 

Anaesthesia 461 

Methods of reduction 462 

Old dislocations . 467 

After-treatment 469 

Habitual dislocation 470 

CHAPTER XXXIV. 

ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE A DISLOCATION . 471 

Integument 472 

Emphysema of the cellular tissue 472 

Rupture of the muscles 473 

Avulsion of a portion of a limb 473 

Injuries of the main bloodvessels 473 

Injuries to nerves 479 

Fracture 481 

Inflammation, suppuration, gangrene 482 

Persistent oedema 483 

Syncope and sudden or early death ; fat embolism 484 

CHAPTER XXXV. 

CONGENITAL DISLOCATIONS. 



Statistics 4£.^ 

Etiology 4g 6 

radiology (hip) 49{) 



xil CONTEXTS. 

PAGE 

Symptoms and diagnosis 493 

Prognosis 495 

Treatment 495 

CHAPTEE XXXYI. 

SPONTANEOUS DISLOCATIONS ^q>j 

By distention 498 

Paralytic 499 

Voluntary 499 

By destruction ; by deformity 499 

CHAPTER XXXVII. 

DISLOCATIONS OF THE LOWER JAW. 

Backward 501 

Backward with fracture 501 

Upward 502 

Outward 502 

Forward 502 

Pathology 503 

Symptoms 505 

Prognosis 505 

Treatment 505 

Pathological 507 

Congenital 507 

CHAPTER XXXVIII. 

DISLOCATIONS OF THE VERTEBRAE AND OF THE OCCIPUT FROM THE ATLAS. 

Classification and pathology 509 

Secondary changes 514 

Etiology 515 

Symptoms and diagnosis 515 

Prognosis , . 517 

Treatment . . 518 

Dislocations of the occiput 519 

Dislocations of the atlas 521 

Dislocations of the lower six cervical vertebrae 524 

Dislocations of the dorsal vertebrae 530 

Dislocations of the lumbar vertebra; 532 

CHAPTER XXXIX. 

DISLOCATIONS OF THE STERNUM. 

Of the body from the manubrium 534 

Of the ensiform process 538 

CHAPTER XL. 

DISLOCATIONS OF THE RIBS AND COSTAL CARTILAGES. 

Of the head of the rib 539 

Of the ribs from the costal cartilages 540 

Of the costal cartilages from the sternum , 541 

Of one cartilage from another 543 

CHAPTER XLI. 

DISLOCATIONS OF THE CLAVICLE. 

1. Of the sternal end 544 

Forward 545 

Backward 548 

Upward _^ . . 550 



CONTENTS. xiii 

PAGE 

2. Of the acromial end 552 

Supra-acromial . . . 553 

Subacromial • 558 

Subcoracoid 56] 

3. Simultaneous of both ends 561 

CHAPTER XLII. 

DISLOCATIONS OF THE SHOULDER. 

Anatomy 563 

Statistics # 567 

Classification 588 

Anterior (and downward) dislocations 573 

1. Subcoracoid 574 

Pathology 576 

Symptoms and diagnosis 579 

2. Intracoracoid 581 

Treatment of anterior dislocations 583 

Direct reposition ; traction downward and outward 585 

Traction upward 586 

Traction with leverage 588 

Heel in the axilla 588 

Forcible traction 588 

Manipulation 589 

After-treatment . 593 

CHAPTER XLIII. 

dislocations of the shoulder — Continued. 

Downward dislocations 595 

1. Subglenoid 595 

Symptoms ; treatment 598 

2. Luxatio erecta 598 

3. Subtricipital dislocation 5P9 

Posterior dislocations (subacromial, subspinous) ... 600 

Symptoms 604 

Diagnosis and treatment 605 

Upward dislocations (supraglenoid, supracoracoid) 606 

CHAPTER XLIV. 

dislocations of the shoulder — Continued. 

Associated injuries and complications ' 611 

Laceration of muscles 611 

Fractures 612 

Nerves 615 

Vessels 616 

Chest. Compound 617 

Simultaneous of both shoulders 617 

Prognosis and after-treatment 618 

Habitual dislocation 620 

Treatment of old dislocations 624 

Subcutaneous section 625 

Arthrotomy 625 

Excision of the head of the humerus 626 

Fracture of the surgical neck 626 

Congenital dislocations 627 

Pathological dislocations and subluxations 632 

Dislocations due to paralysis 633 

CHAPTER XLV. 
dislocations of the elbow. 

Anatomy 635 

Frequency. Classification 6;>7 



xiv CONTENTS. 

PAGE 

Frequency. Dislocations of the forearm backward 638 

Mechanism 638 

Pathology 640 

Complications 641 

Symptoms 642 

Diagnosis 643 

Prognosis 644 

Treatment 645 

Lateral dislocations 648 

Incomplete lateral 649 

A. Inward 650 

B. Outward 652 

Complete outward 655 

Forward dislocations 659 

Divergent dislocations of the radius and ulna 664 

A. Antero-posterior 664 

B. Transverse 666 

CHAPTER XLVI. 

dislocations or the elbow — Continued. 

Dislocation of the ulna alone 667 

1. Backward 668 

2. Inward 671 

3. Forward 671 

Dislocation of the radius alone 671 

1. Backward 672 

2. Outward 675 

3. Forward ■ 678 

4. By elongation, or subluxation in children 681 

Dislocation of the head of the radius with fracture of the ulna 686 

CHAPTER XLVII. 

dislocations of the elbow — Continued. 

Treatment of old dislocations 688 

Congenital and pathological dislocations 693 

CHAPTER XLVIII. 

DISLOCATIONS AT THE WRIST. 

Dislocations of the lower radio-ulnar joint 697 

Backward . , 697 

Forward 698 

Inward and downward 699 

Dislocations of the radio-carpal joint 699 

Backward 701 

Forward 703 

Outward 705 

Pathological ; subluxation forward 705 

Congenital 709 

Dislocations of the carpal bones 710 

Medio-carpal 710 

Midcarpal fracture — dislocation 732 

Isolated dislocations of the carpal bones 716 

Scaphoid 716 

Semilunar 717 

Unciform : pisiform 719 

Os magnum 719 

Trapezoid ; trapezium 720 

Os magnum and trapezoid 721 

Carpo-metacarpal dislocations ....... 721 



CONTENTS. XV 
CHAPTER XLIX. 

DISLOCATIONS OF THE THUMB AND FINGERS. PAGE 

Proximal phalanx of thumb J^6 

Anatomy iZ Jl 

Backward '£' 

Forward \™ 

Lateral J31 

Metacarpophalangeal of the fingers JoZ 

Backward \%% 

Forward 16 { 

Dislocations of the middle phalanges ?3.j 

Backward l%° 

Forward l^ 

Lateral '£■[ 

Dislocations of the distal phalanges £34 

Backward £^2 

Forward 'J** 

Lateral /3 ° 

CHAPTER L. 

DISLOCATIONS OF THE PELVIS AND OF THE COCCYX. 

Dislocations of the pelvis 737 

Dislocations of the coccyx 737 

Forward 738 

Backward 739 

Lateral 739 



CHAPTER LI. 

DISLOCATIONS OF THE HIP. 

Anatomy 740 

Statistics 743 

Simultaneous dislocation of both hips 744 

Compound dislocations 744 

Classification 746 

Backward dislocations 750 

1. Dorsal dislocations 751 

Causes 751 

Pathology 752 

Symptoms 755 

Diagnosis 758 

2. Everted dorsal dislocations 758 

Pathology 760 

Anterior oblique 761 

Symptoms 761 

Treatment of backward dislocations 762 



CHAPTER LII. 

dislocations of the hip — Continued. 

Dislocations downward and inward 767 

Obturator or thyroid dislocations 707 

Cause ,767 

Pathology 768 

Symptoms 769 

Treatment 770 

Perineal dislocations 77*J 

Dislocations upward and forward, and inward and forward (suprapubic) 773 

Eliopectineal ; pubic; intrapelvic , 773 



LIST OF PLATES 



PLATE PAGE 

I. — Recent gunshot fracture of carpus and radius 34 

II. — Same as Plate I., after repair 34 

III. — Fig. 1. Periosteal bridge ; fracture of forearm. Fig. 2. Periosteal 

bridge; humerus; two years after injury 37 

IV — Same as Plate III., fig. 2; injury recent 37 

V. — Fracture of hyoid bone 181 

VI. — Fracture of surgical neck of humerus in a child 237 

VII.— Fig. 1. Skiagram of normal elbow at age of 5 years. Fig. 2. 

Skiagram of normal elbow at age of 8 years 254 

VIII. — Figs. 1 and 2. Cubitus varus ; front and rear views. Fig. 3. 

Frontal sections of same 254 

IX. —Fig. 1. Fracture of lower end of humerus. Fig. 2. Supracon- 

dyloid fracture by extension 254 

X. — Fig. 1. Supracondyloid fracture of humerus by extension. Fig. 2. 

Supracondyloid fracture of humerus by flexion 254 

XT. — Figs. 1 and 2. Supracondyloid fracture 254 

XII. — Fig. 1. Old supracondyloid fracture of humerus ; cubitus varus. 
Fig. 2. Cubitus varus, three years after a low partial supra- 
condyloid fracture 254 

XIII. — Fracture of internal condyle of humerus, in an adult 260 

XIV. — Fig. 1. Fracture of internal epicondyle of humerus. Fig. 2. 

Fracture of external condyle of humerus 260 

XV. — Fracture of external condyle, 18 years 260 

XVI. — Fig. 1. Angular displacement by flexion. Fig. 2. Diacondyloid 

fracture 260 

XVII. — Fig. 1. Fracture of olecranon; dislocation forward of radius and 

ulna. Fig. 2. Fracture of forearm ; angular displacement 274 

XVin.— Fig. 1. Fracture of head of radius. Fig. 2. Fracture of neck 282 

XIX.— Fig. 1. Fracture of humerus by small bullet. Fig:. 2. Fracture 

of forearm 286 

XX. — Fig. 1. Fracture of radius ; marked angular displacement. Fig. 

2. Recent Colles's fracture in a boy 12 years old 292 

XXI. — Fig. 1. Recent Colles's fracture; male," 22 years old. Fii>-. 2. 

Old Colles's fracture.., ! 296 

XXII. — Fig. 1. Recent Colles's fracture, comminuted ; male, 45 years old. 
Fig. 2. Recent Colles's fracture, comminuted; male, 40 years 

old (Plate XXV., fig. 2.) 296 

XXIIL— Fig. 1. Recent Colles's fracture; male, 26 years old. Fig. 2. 

Same as Fig. 1, side view 296 

XXIV.— Fig. 1. Same as Plate XXI II., after reduction. Fig. 2. Recent 

Colles's fracture; male, 56 years old 296 

XXV.— Fig. 1. Recent Colles's fracture; male, 22 years old. Fig. 2. 

Recent Colles's fracture; male, 40 years old 296 

xix 



Xx LIST OF PLATES. 

VLATE PAGE 

XXVI.— Colles's fracture 296 

XXVII. — Fig. 1. Colles's fracture at 12 years; arrest of growth. Fig. 2. 

Separation of radial epiphysis ; boy 15 years old 296 

XXVIII. — Fig. 1. Normal wrist; adult male. Fig. 2. Normal wrist; adult 

female, fracture of third metacarpal 296 

XXIX. — Fracture of scaphoid, and possibly of radius 306 

XXX. — Frature of scaphoid with dislocation of proximal fragment. 306 
XXXI. — Fracture of scaphoid with dislocation of proximal fragment. 306 
XXXII. — Fig. 1. Fracture of carpal scaphoid. Fig. 2. Separation of 

lower epiphysis of femur 306 

XXXIII.— Figs. 1 and 2. Fracture of first metacarpal 310 

XXXIV. — Fracture of acetabulum and displacement of femur inward 322 

XXXV. — Fig. 1. Fracture of neck of femur. Fig. 2. The same after traction. 355 
XXXVI. — Fig. 1. Fracture of patella, five months later ; non-operative 
treatment. Fig. 2. Fracture of patella, two years after me- 
diate suture 381 

XXXVII. — Fig. 1. Fracture of patella, three years after periosteal suture. 

Fig. 2. Fracture of patella, three months after periosteal suture. 381 

XXXVIII. — Fracture of patella. Ossification of ligamentum patella? 381 

XXXIX. — Fracture of upper end of tibia 395 

XL. — Separation of low r er tibial epiphysis 406 

XLI. — Fig. 1. Pott's fracture by eversion in a youth. Fig. 2. Fracture 

of the posterior portion of the low r er end of tibia 406 

XLI1. — Fig. 1. Pott's fracture by abduction. Fig. 2. Pott's fracture, 

two months old; backward displacement 406 

XLIII. — Fig. 1. Pott's fracture by abduction. Fig. 2. Bimalleolar frac- 
ture by inversion 414 

XLIV. — Fracture by eversion with interposition of astragalus 414 

XLV. — Longitudinal fracture of lower end of tibia by a fall upon and 

inversion of the foot 414 

XLYI. — Fig. 1. Bimalleolar fracture by inversion in youth. Fig. 2. 

Fracture of femur remaining ununited a year after wiring 414 

XLVIL— Fig. 1. Long oblique fracture of tibia and external malleolus. 

Fig. 2. Fracture of cuboid 417 

XLVIII. — Figs. 1 and 2. Fracture of os calcis. (Cabot) 421 

XLIX. — Fig. 1. Fracture of os calcis. (Cabot.) Fig. 2. Fracture of 

upper posterior angle of os calcis 471 

L. — Fig. 1. Congenital dislocation of the hip. Fig. 2. Dislocation 

of semilunar bone 493 

LI. — Congenital dislocation of hip 493 

LII. — Old dislocation of shoulder 576 

LIIL— Congenital dislocation of the shoulder 629 

LIV. — Fig. 1. Dislocation backward of elbow. Fig. 2. Dislocation 

of head of radius 678 

LV. — Figs. 1 and 2. Midcarpal fracture dislocation 713 

LVI. — Midcarpal fracture dislocation 713 

LVII. — Midcarpal fracture dislocation, profile view 713 

LVIII. — Midcarpal fracture dislocation 713 

LIX. — Midcarpal fracture dislocation, after removal of proximal frag- 
ment of scaphoid 713 

LX. — Midcarpal fracture dislocation 713 

LXI. — Fig. I . Old dislocation backward of os magnum, side view r . Fig. 

2. Old dislocation backward of os magnum, antero-posterior 719 

LXII. — Fresh dorsal dislocation of the thumb 728 

LXIII. — Fig. 1. Anterior dislocation of the knee. Fig. 2. Posterior 

dislocation of the knee 798 

LXIV. — Incomplete outw T ard dislocation of the knee 806 

LXV. — Subastragaloid dislocation 843 



FRACTURES. 



A TREATISE 



ON 



FRACTURES AND DISLOCATIONS, 



CHAPTEK I. 

INTRODUCTION. 



By Fracture, in the surgical sense of the term, is meant the breaking 
of a bone or cartilage. 

The liability to fracture of the different bones of the body varies 
greatly, in consequence of their differences in size, shape, and degree of 
exposure to external violence or extreme muscular action. Hospital 
records covering periods varying in length from five to eighty-seven 
years have been tabulated by different writers, with the object of deter- 
mining the relative degree of this liability ; but it is evident that such 
statistics cannot contain all the needed facts, for the reason that patients 
with fractures which do not necessitate confinement to the bed do not so 
generally seek hospital care as those with fractures which do. Com- 
bined hospital and dispensary statistics are more nearly correct, but 
even they differ considerably from one another in their percentages, 
possibly because of differences in the occupations and mode of life of 
the communities which furnished them. I have compiled the follow- 
ing table from the records of the House of Relief (" Hudson Street 
Hospital "), of which I am the attending surgeon, including both the 
In- and the Out-patient services. The hospital is the only one in New 
York City below Canal Street, a region largely given over to trade, 
transportation, and manufacturing, with frequent construction of large 
buildings, and in which there is only a laboring resident population. 



Hudson Street Hospital, New York: Statistics of Fractures Treated 
in Hospital and Dispensary, 1894-1905. 

Cases. Cases. For cent. 

Cranium 772 Head 772 5.50 

Malar bone 29 ^ 

Nasal bones 672 j 

Superior maxilla ... 46 I Face and Neck . . . 1281 8.79 

Interior maxilla .... 502 



Zygoma 29 j 

Hyoid 3 J 



19 



20 



FRACTURES. 



Cases. 



Cases. 



Spine 66 "1 

Pelvis 75 | 

Coccyx 3 \ 

Sternum 13 j 

Kibs 1675 J 

" Upper extremity " . . 132 ] 
Clavicle ... ^ ... 662 

Scapula 66 

Humerus, shaft and neck 411 

lower end 209 

internal epicondyle . 6 
Kadius and ulna . . . 283 
Radius, shaft 363 

Colles's 1212 

Ulna, shaft 318 

olecranon 118 

Carpus 15 

Metacarpus 1063 

Phalanges 1990 J 

Femur 540 ' 

Patella 183 

Tibia, or tibia and fibula 943 
Abduction and adduction 

fractures at ankle . 1089 

Fibula 233 [ 

External malleolus . . 33 
Internal malleolus ... 31 

Tarsus 151 

Metatarsus 326 

Toes 334 



Total 



14,566 



Trunk 1832 



Per cent 



12.5^ 



Upper extremity . . 6818 



46.80 



Lower extremity . . 3863 



26.54 



During the same period 1527 dislocations were treated. 

Sex. Fractures are more numerous in men than in women, in the 
proportion of about three to one, because of the greater exposure of 
men to the accidents which cause them. Mainly, for the same reason, 
the proportion varies greatly at different ages ; in infancy the difference 
is slight ; in middle life fractures are ten times as frequent in men as in 
women ; between the ages of fifty and seventy years the difference again 
becomes slight, and after the age of seventy years fractures are more 
common in women than in men, a reversal of conditions due to a dispro- 
portionate increase in the number of fractures of the neck of the femur. 

Age. Gurlt l tabulated 1383 cases (hospital and dispensary) with ref- 
erence to the ages of the patients, and found in the first decade, 265 ; 
in the second, 193 ; in the third, 274; in the fourth, 224; in the fifth, 
154; in the sixth, 155 ; in the seventh, 72 ; in the eighth, 38, and in 
the ninth, 8. Combining these with statistics showing the relative 
number of people living at the different ages, he found the highest 
proportion of fractures in the period above the age of sixty years. 
Malgaigne 2 made a similar tabulation, using only hospital cases, and 
grouping in periods of five years he found that the periods between 
fifty -five and eighty were practically equal to one another, and gave the 
highest proportion according to population. 



1 (lurk : Handbuch (lev Lehre von den Knoclienbriiclien, 1862. 

2 Malgaigne : Traite des Fractures et des Luxations, 1847. 



INTRODUCTION. 



21 



Season affects the frequency of fracture only by increasing or dimin- 
ishing the exposure to the accidents which occasion them. Falls due 
to ice and snow in winter are more than offset as a cause by the more 
varied and active occupations of the milder months, and fractures are, 
therefore, less frequent in winter than in summer. This is shown by 
the following tabulation of the fractures treated in the Hudson Street 
Hospital, according to months : 



Hudson Street Hospital : Fractures in 1896, Wards and Dispensary. 



January, 

February, 

December, 



Omitting hand \ 
and toes, J 



77 

88 

119 

284 
57 

227 



March, 

April, 

May, 



130 

103 

97 

330 
84 

246 



June, 
July, 

August, 



82 
148 
150 

380 
104 

276 



September, 

October, 

November, 



105 
107 
116 

328 
92 

236 



The maximum is found in the summer months, the minimum in the 
winter. It is only in fractures of the leg that the winter season heads 
the list, and yet even in these, as the following table shows, a decided 
monthly maximum is found in March, a month in which there is but 
little snow and ice in New York : 



Fractures of the Leg, of either Bone, and Pott's Fracture. 



January, 


19 


March, 


29 


June, 


9 


September, 


8 


February, 


20 


April, 


9 


July, 


11 


October, 


6 


December, 


21 


May, 


12 


August, 


25 


November, 


20 



60 



50 



45 



34 



Fractures of the femur (shaft and neck) give the following totals : 
Winter 16, spring 17, summer 8, autumn 12 ; those of the upper ex- 
tremity (clavicle, humerus, and either or both bones of the forearm) 
give : Winter 67, spring 63, summer 107, autumn 72. 



Note. — For other statistics see Malgaigne, Gurlt, and the first edi- 
tion of this work ; also Wallace, American Journal of the Medical 
Sciences, 1839 ; Norris, Ibid., 1841 ; Lente, New York Medical Journal, 
1851; Lonsdale, Fractures, 1838, and Scannell, Boston Medical and 
Surgical Journal, Nov. 15, 1906. 



CHAPTEE II. 

PATHOLOGY. 

The Bone — Varieties : Incomplete, Complete, Multiple, Compound, Gunshot. 
Displacements. The soft parts. 

(A) THE BONE— VARIETIES OF FRACTURE. 

The varieties of fracture are numerous and are constituted by 
differences in the extent of the injury to the bone or to the surrounding 
soft parts, in the seat, shape, and direction of the fracture, in the rela- 
tion of the fragments to each other, and in the number of bones 
involved. These varieties may be grouped in five divisions, marked 
by important clinical differences and containing many subdivisions, as 
follows : 

1 . Incomplete fractures. 

(a) Fissures. 

(b) True incomplete, " green stick ;" bent bone. 

(c) Depressions. 

(d) Separation of a splinter or of an apophysis. 

2. Complete fractures, subdivided, according to 

(a) Direction and character of the line of fracture, into transverse, 
oblique, longitudinal, spiral, toothed or dentate, V-, Y-, or T-shaped, 
and comminuted ; 

(6) Seat of the fracture, into fracture of the shaft, of the neck, of the 
upper, middle, or lower third, intercondyloid, separation of epiphysis ; 
and 

(c) If extending into a joint, intra-articular. 

3. Multiple fractures, comprising fractures of two or more non- 
adjacent bones and two or more fractures of the same bone. 

4. Compound (or open) fractures. 

5. Gunshot fractures. 

The term simple (or closed) fracture is commonly used, in contradis- 
tinction to the term compound, to indicate that there is no associated 
wound of the soft parts which establishes communication between the 
fracture and the exterior. 1 Some writers make also a class of compli- 
cated fractures to include cases in which some important injury coexists ; 
and there are still other terms in use to indicate peculiarities which do 
not lend themselves easily to the above classification. Such are : Spon- 
taneous fracture, one produced by the minimum of violence ; pathological 
fracture, one favored by weakening or partial destruction of the bone by 
disease ; direct fracture, one occurring at the point where the causative 

1 Of late an effort has been made to substitute the use of the term open for compound, 
and closed for simple, but it does not appear to have gained much momentum or that there 
is urgent need of the change. The significance of compound is freely and widely under- 
stood, without, as well as within, the profession ; that of simple is perhaps not so well under- 
stood and is occasionally liable to misinterpretation. 
22 



PATHOLOGY. 



23 



external violence is received ; indirect fracture, one occurring at a dis- 
tance from that point ; recent and old, or ununited, fracture. Another 
grouping is according to the mechanism of production : fractures by 
bending, by torsion, by crushing, by avulsion, by gunshot ; with sub- 
sidiary terms : fractures by flexion or extension, by abduction or adduc- 
tion, by eversion or inversion. 



Fig. 1. 



1. Incomplete Fractures. 

Under this head will be considered fractures in which the continuity 
of the bone has not been completely lost or a fragment has not been 
completely detached. 

(a) Fissures. This variety is characterized by the existence of a 
split or crack in the bone, one which does not entirely circumscribe a 
fragment and separate it from the rest of the bone. It is of common 
occurrence in the bones of the cranium, and very rare in the long bones 
except when associated with other varieties. It is almost unknown in 
the short or spongy bones. 

The examples of isolated fissure of long bones are very rare. Fig. 
1, copied by Gurlt from Froriep, represents one extending from the 
greater tuberosity of the humerus to the lower fourth of the shaft, pro- 
duced in a boy by a fall upon the elbow. Fissures connected with 
complete fracture are common ; are sometimes very long, and may 
extend into a neighboring joint. A very long fissure is sometimes 
termed a longitudinal fracture. 

The mechanism by which a long 
isolated fissure is produced in a long 
bone is probably the forcible bend- 
ing of the bone. This is plainly 
indicated in a case reported by De- 
brou in 1843, and quoted by Gurlt as 
a case of infraction. The patient, a 
man sixty-two years old, fell while 
walking, and injured his thigh. Ery- 
sipelas set in and caused his death. 
At the autopsy a fissure was found 
under the untorn periosteum, extend- 
ing six inches downward from the tro- 
chanter minor, and this fissure could 
be made to widen by pressure upon 
the ends of the bone. 

The diagnosis cannot be made with 
certainty, except when the bone is ex- 
posed to direct examination ; but it 
can be inferred with much proba- 
bility in some forms of fracture with 
which it is usually associated, such as 
V-shaped fractures of the tibia. G iese, 1 
reporting a case involving the tibia, calls 
attention to the discrepancy between the slight objective signs and the 
extreme sensitiveness and interference with function, 

'(.Jit'se: Miinchener med. Wochenschrift. 1906, No. 9. 




Fissure of 
the humerus. 

((iURLT.) 



Partial fracture of the 
fibula, a, the head : b, 
the malleolus. 



24 FRACTURES. 

Except when it extends into a joint the importance of a fissure i* 
probably slight, and is dominated by that of the associated lesions. In 
some cases the injury has been promptly or tardily followed by suppura- 
tion beneath the periosteum or within the bone. 

(6) True Incomplete, " Green- stick Fracture " ; Infraction; Bent Bone, 
or Curvature Without Fracture. This variety is characterized by a frac- 
ture involving only a portion of the thickness of a long bone, and 
combined with a bending of the bone at the seat of fracture. In its 
consideration is included also that of the rare cases of curvature with- 
out recognizable fracture, a variety which has only an academical 
interest, for it cannot be recognized clinically. Its possibility has been 
demonstrated experimentally upon young animals and by a single 
specimen belonging to Prof. Uhde, the ulna of an adult much bent by 
a machinery accident, and showing no trace of fracture. 

The injury appears ordinarily as a short transverse fracture, continu- 
ous with one or more longitudinal ones of variable length ; sometimes 
there is no transverse line, but only oblique ones running from the 
angle upward or downward. The appearance can be closely imitated 
by over-bending a green or tough stick, a fact that has given this form 
of fracture a name by which it is very commonly known. 

This fracture is seen most frequently in the bones of the forearm, 
then in the clavicle, and very rarely in the bones of the arm, leg, and 
thigh. The great majority of cases occur in those under the age of 
fifteen years. In the forearm it may be found in only one bone, the 
other being completely broken. The usual cause is a fall, but I have 
seen several cases in which the cause was the forcible bending of the 
forearm over a rigid body, as when the limb is caught between a shaft 
and its belting. 

The chief symptoms are deformity, consisting in an angular devia- 
tion of a portion of the limb or bone, and localized pain on pressure at 
the angle. The deviation can be more or less completely corrected by 
the use of force, and the correction may be accompanied by crepitus and 
followed by abnormal mobility, the fracture having been made complete. 

The prognosis is favorable as regards correction of the deformity and 
repair. Ordinarily, the limb can be straightened by the surgeon's 
hands alone, aided, perhaps, by the pressure of his knee against the 
angle ; and the surgeon should not be deterred, by the fear of making 
the fracture complete, from using all the force that is necessary. 
„ (c) Depressions. I limit the use of this term to those cases in which 
a portion of the outer layer of a flat bone or the spongy portion of a 
long bone is driven inward by direct violence, usually a blow with a 
pointed instrument. The injury is most frequently seen in the vault 
of the skull, and is there generally termed a fracture of the outer table. 
It is occasionally seen in the limbs in connection with complete fracture. 

(d) Separation of a Splinter or of an Apophysis. In this variety are 
included two classes of fractures which differ widely in their mode of 
production, but have this in common : that the fragment does not com- 
prise the entire breadth or thickness of the bone, and that consequently 
the continuity of the latter is not destroved. In the first class a 



PATHOLOGY. 



25 



splinter or fragment of bone is broken off by direet violence, as by a 
cutting instrument ; in the second class a bony prominence is torn off 
by the violent contraction of the muscle attached to it or by traction 
through a ligament. 

The separation of a splinter or scale of bone by a sword-cut or bullet 
is not uncommon in the spongy bones or the spongy extremities of long 
bones, and has also been known to occur, in the shaft of the tibia. It 
is an injury which should be classed rather among wounds of bones 
than among fractures. The separation of a splinter by direct violence, 
unaccompanied by a wound of the soft parts, occurs in the bones of the 
face, at the crest of the ilium, and at exposed points upon the extremi- 
ties of the long bones. 

Avulsion of an apophysis, or of a scale of bone, by muscular action 
is a far more common accident than the one just described. The lesion 
consists in the fracture of an apophysis at its base or in the tearing 
off of a portion of bone to which a muscle or tendon is attached. 



2. Complete Fractures. 

The term complete, when applied to a fracture of a long bone, indi- 
cates that the bone is divided by a line of fracture crossing from side 
to side or obliquely across the end. 



Fig. 3. 



Fig. 4. 



Fig. 5. 




A 



\ 




Humerus. 



Femur. 
(Tracings from skiagrams. 



Femur. 



(a) Subdivision According to the Direction of the Line of Fracture. 
Such terms in use are transverse, oblique, splintered, spiral, V-shaped, 



26 



FRACTURES. 



as 



T- or Y-shaped, dentate, longitudinal, and comminuted. Apparently 
a result of physical conditions, fractures by direct or indirect violence 
which bend a long bone are either practically transverse or markedly 
oblique, with or without splintering. 

The line of a transverse fracture does not deviate more than about 
15 or 20 degrees from that of the transverse axis; that of an oblique 
fracture lies near an angle of 50 degrees. A transverse fracture may 
be, but rarely is, exactly transverse and smooth (Fig. 6) ; clinically 
such details cannot be recognized unless the fracture is compound, and 
the diagnosis of the variety is made on the fact that the end of the 
fragment can be felt through the overlying soft parts to be approximately 
square and smooth. In the oblique variety the line of fracture may be 
single (Fig. 9) or multiple (Fig. 8), circumscribing in the latter case 



Fig. 



Fig. 





Transverse fracttire of the 
femur. (Gurlt.) 



Fracture of humerus. 
(V. Bruns.) 



one or more detached fragments which apparently are formed on the 
side of the concavity created by the bending of the bone {splintered). 
This is characteristic of the fractures produced by bending. The line 
of fracture in either form may be markedly irregular on either or both 
fragments. When this irregularity is found on both fragments the 
term toothed or dentate is applied ; when it is found only on one side 
the absence of a corresponding line on the other is due to the crushing 
of the bone or to the splitting off of one or more large fragments. 
Spiral fractures, which are rare, are produced by torsion of the bone, 



PATHOLOGY. 



27 



and are found in the femur, humerus, and tibia. In the latter they are 
better known as V-shaped (Fig. 10), and can be readily recognized 



Fig. 8. 



Fig. 9. 





Oblique fracture by direct pressure. 
(Kocher.) 



Spiral fracture by outward rotation of 
lower end. (Kochek.) 



by the sharp point of the upper fragment, which can be felt midway 
between the crest and the internal border of the bone. From the 
re-entrant angle corresponding to this point a fissure runs down to the 
ankle-joint. 

Under the term longitudinal are included very oblique fractures run- 
ning from one side of the bone to the other, fractures running from 
one end of the bone to or nearly to the other, and fractures which split 
lengthwise a long fragment intermediate between two transverse frac- 
tures. The last-named form is produced only by great crushing 
violence, and the prognosis is very bad. In the other forms the 
violence is indirect, apparently a bend or twist of the bone or a blow 
received at one end ; the ill results which have so commonly followed 
appear to be due in some to the implication of one or both joints or to 
a failure to recognize the injury and maintain immobility. The most 
marked cases are one reported by Kronlein, 1 a fracture of the humerus 
1 Kronlein: Deutsche Zeitsoh. f. Chir., 1ST;?, p. 13:2. 



28 



FRACTURES. 



from the shoulder to the elbow-joint, in a man twenty-seven years old, 
by an attempt to raise a heavy ladder, and one by Cloquet, in 1831, a 
fracture of the femur from the intercondyloid notch to 
a point just below the trochanter minor, by a fall from FlG - 10* 
a roof. 

A comminuted fracture of the shaft of a long bone is 
one in which, in addition to the complete division of the 
bone into two fragments, there is also extensive splinter- 
ing of the portion of bone adjoining the fracture or of 
one of the fragments (Figs. 11 and 12). In a comminuted 
fracture of a flat bone the bone or a portion thereof is 
broken into several rather large fragments, with or 
without additional small ones ; in this use of the term 
fractures showing only two or three fragments, and 
those rather small, are excluded, the line of distinction 
being of necessity vague and arbitrary. In the short 
bones and the spongy ends of the long bones comminu- 
tion is frequently associated with crushing of the spongy 
tissue, or the end of the diaphyseal fragment may be 
driven into the expanded, spongy end, crushing it or 
splitting it ; to this form the term compression fracture 
is sometimes given, specially at the upper end of the 
humerus and tibia and in the bodies of the vertebrae. 
If the two main fragments are rather firmly held to- 
gether in their new relations the condition is termed 
impaction or impacted fracture (Fig. 13). If the crush- v-snaped fracture. 
ing of the spongy tissue has taken place without much 
splintering of the cortical layer the term fracture with crushing is used 
(Fig. 14). This crushing of spongy tissue is effected by breaking 
Fig. 11. Fig. 12. 





Comminuted fracture of the femur, 
with splitting of the condyles. 



Comminuted fracture of the lower 
end of the radius. Palmar aspect. 



PATHOLOGY. 



29 



down the innumerable fine lamellae of bone and forcing out the fat 
within the meshes, as a handful of snow or a wet sponge is compressed, 
and the result is equivalent to an actual loss of tissue ; that is, if the 
main fragments are replaced in their original positions a gap is left 
between them corresponding to the position and extent of the crushing. 
This gap is often too large to be filled by new bone, formed during 
repair ; consequently, a full correction of the displacement is inadvis- 
able, even when possible, lest failure of union should result, and the 
surgeon must be content to obtain union with some deformity. 



Fig. 13. 



Fig. 14. 




Intra-articular fracture of the head 
of the tibia, with impaction and sepa- 
ration of the upper fragments. 



Fracture of the calcaneum, with crushing. 



(b) Varieties Dependent Upon the Seat of the Fracture. — A fracture 
may occupy any portion of the bone and be known by its name ; for 
example, fracture of the neck of the femur, of the lower third of the 
tibia, of the head, of the shaft, of the inner condyle, of the acromion ; 
intercondyloid fracture, when it passes across the shaft and also down- 
ward between the condyles ; separation of the epiphysis. 

Separation of the Epiphysis. 1 This term is limited to separation of 
epiphyses which have not yet become united by bone with the shaft. 
This union takes place in the different bones at different ages, but is 
usually complete in all in the female at the age of twenty-two years, 
and in the male at twenty-five years. Bruns 2 collected 81 cases, with 
101 separations, in which direct examination of the seat of injury was 
possible ; the points of greatest frequency were the lower end of the 
femur 28, lower end of the radius 25, and upper end of the humerus 
11. Of the 52 cases in which the age was given, 44 were between 
ten and nineteen years old, 8 between one and nine years. Of 61 in 
which the line was exactly described, the line in 23 ran exactly along 
the face of the conjugal cartilage, in 5 it ran through the cartilage, 
and in 33 partly along the cartilage and partly through the adjoining 

1 The first work upon this subject is by G. C. Reichel, " De Epiphysium ab Ossium 
Diaphysi Diductioue," published at Leipsic in 1794. Manqnat's tbesis, in 1ST?, and 
Bruns' article, in 1878, wore the first in which any considerable number ot* cases was 
collected. Later articles will be referred to in connection with the different epiphyses. 
Quite recently. 1898, a large work upon the subject has been published bv John Poland 

' 2 Bruns: Arch. i". klin. Chir., 1878, vol. xxii. p. 343. 



30 



FRACTURES. 



" chondroid " tissue on its diaphyseal side. An important feature is 
the fact that the periosteum of the adjoining portion of the shaft is 
freely stripped off, preserving its continuity to a large extent with the 
epiphysis. It has lately been recognized that a partial or complete 
separation of the epiphysis of the lower end of the humerus is frequent. 
(See Plates XI. and XII.) 

The mode of production appears usually to be by cross-strain, the 
limb being bent beyond the limit of normal motion in the correspond- 
ing joint or in a direction in which there is normally no motion ; for 
example, lateral bending at the knee. 

The displacement may be very slight or so great as wholly to sepa- 
rate the fractured surfaces from each other. Colles's fracture at the 
lower end of the radius in the young is occasionally a separation of 
the epiphysis with slight displacement (see Plate XXVII. , Fig. 2) ; at 
the upper end of the humerus the displacement is usually equal to 

Fig. 15. 




Separation of the epiphysis. Periosteum partly intact. (Thudjcum.) 

about half the thickness of the bone ; at the elbow it may be complete 
backward or inward, but is usually incomplete inward. 

The diagnosis is made in the cases of slight displacement on the 
history of the injury and tenderness on pressure limited to the line of 
junction of the epiphysis and shaft; in the others by recognition of the 
deformity and of the size and shape of the fragment. AVhen the dis- 
placement is great reduction may be seriously opposed by the interpo- 
sition of the loosened periosteum. 

The prognosis is affected by the possibility of arrest of growth due 
to an uncorrected displacement or to premature ossification of the con- 
jugal cartilage. A few such cases have been reported. This defi- 
ciency of growth is, of course, most marked in those who receive their 
injury at an early age, and secondly in those cases in which the 
affected epiphysis normally takes the larger part in the growth of the 
bone in length, namely, the upper end of the humerus and tibia and 
the lower end of the femur and radius. I have seen two cases in 
which this injury at the lower end of the radius at the age of fourteen 



PATHOLOGY. 31 

years produced a late deformity exactly resembling that of a very bad 
Colles's fracture. (See Plate XXVII., Fig. 1.) 

(c) Intra-articular or articular fractures are those iu which the main 
line of fracture or a subsidiary one, extends into a joint. The forms 
vary from a simple fissure extending into the joint from a distant frac- 
ture with little or no injury to the capsule to a fracture in which the 
articular end of a bone is broken into several widely displaced pieces 
with much laceration of the capsule and periarticular tissue. They 
include also that form in which the fracture lies wholly within the joint, 
with little or no injury to the joint, as in fracture of the narrow part 
of the neck of the femur, close to the head, and in fracture of the capi- 
tellum of the humerus, and some fractures of the carpal scaphoid ; to 
this form the term intra-articular is often limited. Common examples 
are fractures of either condyle of the femur or humerus, intracondyloid 
fractures of the same bones, fractures of the patella and olecranon. 
The special importance of the variety arises partly from the implication 
of the joint in the inflammatory reaction following the trauma, but 
mainly from the change in the mechanical conditions produced by the 
displacement of the fragment, the callus, and the implication of the 
capsule and periarticular tissues. There is but little recognizable 
regularity in the effects produced by these different factors, lesions 
apparently slight sometimes causing complete anchylosis, and extensive 
displacement of a fragment sometimes causing only slight interference 
with function. The most marked limitations of motion appear usually 
to be the consequence of injury to the capsule and adjoining soft parts 
by which they are shortened or so bound together as to restrict the 
movements. This factor needs specially to be borne in mind in decid- 
ing upon the propriety of operation in these cases and upon the method 
of operation. When a fragment including a portion of bone well out- 
side the capsule has undergone such displacement, usually by rotation, 
as to separate its articular portion wholly or in great part from the cor- 
responding surface of the associate bone an operation is usually required 
to restore it to its place. If the fragment is smaller and wholly intra- 
articular, or even if retaining slight capsular connection, it is usually 
better to remove it, for it is unlikely to maintain its vitality. In the 
young excessive formation of bone outside of, but near to, the joint as 
the result of the traumatic irritation of the periosteum may also me- 
chanically limit the motions of the joint. 

3. Multiple Fractures. 

This term is applied to the simultaneous fracture of two or more 
non-adjacent bones and two or more fractures of the same bone whose 
lines are not continuous with one another. The term double is also 
used when there are only two fractures. This definition is intended 
to exclude simultaneous fracture of both bones of the leg or forearm 
and fractures which involve two or more adjacent bones of the skull 
or pelvis. The term is frequently applied to fracture o{' two or more 
adjacent ribs, and sometimes to cases of extensive splintering of the 
flat bones. 



32 FRACTURES. 

Multiple fractures of a single boue are caused by violence, usually 
great, acting in part directly against the shaft, as the fall of a heavy 
weight or, as in two of my own cases, by the striking of the thigh 
against a tree when the patient was thrown from a carriage. The 
condition may be serious as to life, because of the shock of the injury, 
and in respect of restoration of form and function, because of the diffi- 
culty of controlling the position of the intermediate fragment. There 
is also the chance of overlooking one of the fractures. 

Multiple fractures of different bones are also usually caused by 
great violence ; the prognosis is affected much more by the associated 
injuries and shock than by the multiplicity of ihe fractures. If the 
patient survives the primary effects of the accident the fractures heal 
in the ordinary manner. 

4. Compound (or Open) Fractures. 

A compound fracture is one in which communication between the 
fracture and the external air is established through a wound of the 
soft parts. The importance of this communication arises through the 
possibility of infection of the wound from without, with all the risks 
involved in the consequent suppuration of the bone and the lacerated 
soft parts. In addition, a large proportion of compound fractures are 
caused by direct violence, and the consequent laceration of the over- 
lying soft parts is such as to be a serious addition to the fact of fracture. 
In other cases the external wound may be merely a puncture made by 
the broken end of the bone, which, under suitable treatment, heals in 
a few days, making the fracture thenceforth a simple (closed) one. 

A fracture that is simple at first may be made compound by the 
sloughing of the overlying skin in consequence of its injury by the 
primary violence or of pressure upon it by a displaced fragment, or 
by the later forcing of the sharp end of a fragment through the skin 
in the agitation of delirium or in an attempt to use the limb while in 
ignorance of the character of the injury that has been received. 

In determining the compound character of a fracture it is sufficient 
to establish the fact that the wound of the soft parts extends through 
the enveloping fascia and to the immediate neighborhood of the seat 
of fracture, for even if the gross lesion should not extend to the 
broken surface of the bone, yet the minuter lacerations and the 
extravasated blood create a path for the spread of infection that brings 
the condition fully within the definition and the special dangers. 

The prognosis varies so greatly with the extent and character of the 
injury to the soft parts that statistics which take no account of these 
variations have but little value. A fracture produced by indirect 
violence and made compound by a puncture of the skin by the end of 
a subcutaneous bone, such as the ulna or tibia, may be confidently 
expected to heal under appropriate treatment as kindly and promptly 
as a simple fracture ; while one produced by direct violence and 
accompanied by destruction of the skin and muscles can heal only by 
granulation, and will probably suppurate, notwithstanding all the care 
that may be given it j or, the associated damage to the soft parts may 



PATHOLOGY. 33 

be such that the limb would be useless even if the wound should heal. 
The most virulent and rapidly progressive infections appear with ex- 
ceptional frequency in compound fractures accompanied by much bruis- 
ing or laceration of the muscles ; their production is presumably favored 
by the local reduction of vitality. 

The shock of the injury is usually much greater than that of simple 
fracture, and may cause death in a few hours, and the probability of 
the existence of serious associated lesions is also greater because of the 
usually greater violence that has produced the fracture. This is shown 
by the following statistics: During two years, February, 1895, to 
February, 1897, there were received at the Hudson Street Hospital 
70 compound fractures of the limbs, exclusive of those of the hand. 
Eleven of these patients died within twenty-four hours after the acci- 
dent, 3 of the 11 having also a fracture of the base of the skull ; 4 
more died within three days after the accident, making in all 15 
deaths (or 12, if the fractures of the skull are excluded) directly due 
to the shock of the injury, a mortality of 21 per cent. This is largely 
in excess of that following simple fractures, although they, too, may 
be aocompanied by other grave lesions or by severe shock, or may 
lead to a fatal pneumonia or attack of delirium tremens. I cannot 
give the final result in the remaining 55 cases of my list, because 
many of them were transferred to their homes or to other hospitals 
after they had recovered from the primary effects of their injuries. 
At least three of them underwent amputation. 

Mumford, 1 collating 300 cases (excluding those that died within the 
first twelve hours and those treated by primary amputation) received 
at the Massachusetts General Hospital during the preceding eight 
years, found a mortality of 30, or 10 per cent., the causes of death 
being sepsis, 10; shock, 7; delirium tremens, 6; fat embolism, 3; 
gangrene, 3; nephritis, 1. The highest mortality was in fractures of 
the femur — 25 cases with 7 deaths, 28 per cent. 

The principles of treatment are to transform the fracture into a 
simple one as promptly as possible, to minimize suppuration and keep 
it superficial when it is inevitable, and to protect against other infec- 
tion while the wound is open, meanwhile immobilizing the fragments 
by suitable splints. Under the protection of strict asepsis (including in 
that rigid disinfection of the crushed soft parts in fractures by direct 
violence) the question of the need of amputation may often be post- 
poned until after the progress of the case shall have clearly shown 
whether or not the limb can be saved. 

5. Gunshot Fractures. 

The call for separate consideration of this variety of compound frac- 
tures comes through peculiarities of the lesions and dangers consequent 
upon the small size and the velocity of the projectile. The subject, 
consequently, is rather more limited than its title might suggest, and 
does not include fractures bv large balls or nieces of shell, in which 



^ 



or piece 



1 Mumford : Boston Medical and Surgical Journal, May 10, 1S94. 



34 



FRACTURES. 



the extensive laceration of the soft parts is even more important than 
the fracture. 

The special features are the usually extensive splintering and As- 
suring of the hone and the bruising of the tissues along the track of 
the bullet which may prevent prompt healing of the wound. These 
features are found in varying degrees, corresponding to the velocity of 
the ball and to its size. A ball whose force is nearly spent may, on 
striking the shaft of a long bone, do no injury at the point of impact, 
but may yet cause a curved fissure nearly circumscribing a cortical frag- 

Fig. 17. 




Contusion of side of femur by pistol-ball ; " symmetrical " 
fissure of the opposite side. (Potjlet and Bousqtjet.) 



Transverse fracture of the clavicle 
by a spent ball. (Ricard.) 



ment on the opposite side (Delorme, Fig. 16) ; if its speed is slightly 
greater, and especially if it strikes the spongy end of the bone, it causes 
a depression of the surface only ; if the ball is large and its velocity 
low, and the point struck is near the centre of the shaft, a transverse 
fracture (Fig. 17) or an oblique one (Plate XIX.) may be produced. 
At higher velocities the bone is perforated, with more or less splinter- 
ing and Assuring (Fig. 18), or the entire cylinder for a length of one 
or two inches is split into small fragments which are driven far into 
the surrounding tissues (Fig. 19). See also Plate I. With the latter 
may be associated extensive lacerations of the soft parts on the distal 
side. In other cases the bone is fissured or split into large fragments 
on each side. Occasionally the bone may be simply perforated or 
notched, and then broken by the subsequent use of the limb. I have 
seen two such cases ; in one the patient was shot by a policeman, and 
as he ran away the femur broke at the point where it had been perfo- 



PLATE I 




Fracture of Radius by Small Bullet of High Velocity entering 
at the Hand and emerging at the Elbow, 



PLATE II 




Same Case as Plate I., after Repair 



PATHOLOGY 



rated ; he died of tetanus. In the other, fracture of the leg, the same 
sequence was observed, but the patient survived, and the exact charac- 
ter of the injury caused by the bullet remained unknown. 

In the case shown in Plate I., in which the ball entered between the 
fingers and emerged above the elbow after extensively splintering the 



Fig. 18. 



Fig. 19. 




Perforating shot wound of tibia. 
(Ricard.) 



«, entrance ; b, exit. 




Fracture 
ball from 
small 
locity 



of femur by 

Lobel rifle ; 

calibre ; high ve- 

(Chatjvel and 



NlMIER.) 



lower half of the radius, the skin of the forearm 
was torn longitudinally in several places, apparently 
by the distending effect of the ball. 

In fractures by a charge of small shot at close 
range the laceration of the soft parts is the pre- 
dominant feature. In those of the cranium, chest, 
and pelvis the associated visceral injuries are the 
most important ; thus, one of my patients died 
from the injury done to his brain by a single bird 
shot, size No. 7, which entered through a very thin part of the frontal 
bone just below the inner end of the eyebrow. The removal of the 
bullet, even from the brain, is not essential to recovery, and a search 
for it may easily be harmful. 

The great mortality which formerly characterized these injuries has 
been greatly reduced by antiseptic treatment. In military surgery the 
gain in saving life and limb has also been increased by the reduction 
in the size of the bullet and possibly also by its higher velocity. In 
civil practice, which deals mainly with pistol-shot wounds, the results 
now obtained are good. A pistol-shot wound is usually surgically clean, 
and if not officiously treated may be confidently expected to heal kindly ; 
a piece of the clothing is rarely carried in by the bullet, and in most 
cases all that is necessary is to clean the surface and the orifice of the 
wound and apply a dressing. The bullet may be left to heal in unless 
the wound is large and ragged. Late hemorrhages, due to the slough- 
ing of bruised vessels, sometimes occur. 



36 FRACTURES. 

Displacements. 

The relations of the two principal fragments produced by fracture 
of a bone may be altered in various ways, which Malgaigne classified 
under six heads. The classification has been generally adopted, with 
the understanding, however, that a fracture usually presents a combi- 
nation of two or more of them, and that there is an additional group 
of cases in which the peculiarities of the displacement defy classification. 

The six classes group displacements according to 

1. The transverse axis of the bone, transverse or lateral displacement. 

2. The long axis of the bone, angular displacement. 

3. The circumference of the bone, rotatory displacement. 

4. The length of the bone, overriding. 

5. Penetration of one fragment by the other, impaction or crushing. 

6. Direct longitudinal separation. 

1. Transverse or lateral displacement may take place forward, back- 
ward, or toward either side, and may be partial or complete. Pure 
transverse displacement is rare ; it is usually associated with over- 
riding or angular displacement, or both (Plate III., fig. 1). 

2. Angular displacement may vary in degree from a slight deviation 
to a right angle, or even more, and may be associated with so com- 
plete and distant separation of the broken surfaces that the fragments 
form a T (Fig. 20). It may be produced by the fracturing violence, 
the action of gravity, or the contraction of the muscles. 

3. In rotatory displacement one fragment, usually the lower, turns 
about its long axis, while the other fragment remains in position. 

4. Overriding is most common after oblique fracture of the shaft, 
and is produced by various causes, such as a continuation for a moment 
after the fracture of the force that has produced it, the tonicity of the 
muscles, or the swelling of the limb due to inflammatory reaction and 
extravasation of blood beneath the deep fascia, which, by increasing 
the transverse diameters, shortens the longitudinal one. 

Fig. 20. 




Fracture of the clavicle. 

5. Displacement by penetration or crushing has been already men- 
tioned as the impacted variety of fracture. Penetration rarely takes 
place without a change in the direction of the axes of the fragments, 
because of differences in the resistance or of the direction of the 
fracture. 

The callus found after consolidation of the fracture may give the ap- 
pearance of a much deeper penetration than has actually taken place ; 
thus, in Fig. 23 the triangular mass of spongy tissue on the side is 



PLATE 111 




Fig. 1.— Fracture of Forearm, Six Weeks Old, showini 
along Periosteal Bridge. 



Ossification 




Fig. 2.— Humerus 



Two Years after Fracture 
Periosteal Bridge. 



Growth of Bone along 



PLATE IV 




Same as Plate III., Fig. 2. Injury recent. 



PATHOLOGY. 



37 



not the penetrated epiphysis, but is mainly composed of callus formed 
by the stripped-up periosteum. v 

6. Direct longitudinal separation is seen most frequently after fracture 
of the patella, and is then due partly to the retraction of the quadri- 
ceps and partly to the distention of the joint by blood and exudate. 



Fig. 21. 



Ftg. 22. 



Fig. 2- 




Rotatory displacement after frac- 
ture of the neck of the femur. 



Fracture of the lower end of 
the radius. Angular displace- 
Fracture of both bones of the ment of the lower fragment 
leg, with overriding. backward. (R. W. Smith.) 



Among the irregular displacements, those which do not fall entirely 
within the above classification, may be mentioned rotation of one frag- 
ment about its transverse axis, as in some fractures of the neck of the 
humerus, crossing of the fragments in the form of an X, and the inter- 
position of a bone between two fractured ones, or of the end of the 
shaft between its separated condyles. 



(B) THE SOFT PARTS. 

The periosteum may be simply loosened from the surface of bone 
adjoining the fracture, or it may be torn across throughout the whole 
or only a portion of its extent at or near the line of fracture. The 
first form (excluding fractures of the flat bones') is found only in frac- 
tures with slight displacement, and especially in the young, in whom 
the periosteum is thick and resistant. Such fractures are known as 
subperiosteal. They may be recognized or inferred from the youth of 



38 



FEACTUBES. 



the patient and the slight displacement and mobility of the fragments. 
Their prognosis is exceptionally good. 

Complete rupture of the periosteum all around the bone is probably 
infrequent and to be found only in fractures with great displacement. 
Examination of fresh specimens and of the position and shape of the 
callus in those that have united indicates that in most cases the conti- 
nuity of the periosteum is preserved on one side, the continuous portion 
being stripped off one of the fragments for some distance and forming 
a " periosteal bridge" (Oilier), which unites the two fragments and 
takes an important part in the subsequent repair. (Plate III. and 

Fig. 24. 




" Periosteal bridge," diagrammatic. 



The muscles may escape injury or may be extensively torn. The 
neighboring connective tissue is torn and infiltrated with blood from its 
own vessels or from those of the broken bone. Injury to important 
vessels and nerves is rare ; it w T ill be described under Complications, 
Chapter VI. 

The skin may be torn by the original violence or by the sharp end 
of a fragment, or it may be so bruised by the original violence or so 
pressed upon by a displaced fragment that it subsequently sloughs. 
These lesions of the skin may communicate with the seat of fracture 
(compound fracture), or may be at a distance therefrom and without 
influence upon its course, except so far as they may interfere with the 
application of splints. Discoloration of the skin due to extravasated 
blood beneath almost invariably appears after a day or two, and may 
be widespread. Large blebs filled with dark, blood-stained serum fre- 
quently appear upon the limb near the fracture by the second or third 
day. 



CHAPTER III. 

ETIOLOGY. 

Predisposing Causes — Determining Causes— Spontaneous and Pathological 
Fractures — Intra-uterine Fractures and Fractures During Delivery. 

The causes of fracture may be grouped under two heads: A. The 
predisposing causes; B. The immediate or determining causes. 

The Predisposing Causes 

are of three kinds : (1) the external, (2) the normal or physiological, 
and (3) the pathological. Most of the latter, which consist in a local 
or, more rarely, a general diminution of the strength or an actual de- 
struction of the bone by a local or general disease, will be considered 
under the head of Spontaneous or Pathological Fractures. 

The external predisposing causes are those incidental to various occu- 
pations and modes of life which involve greater exposure to deter- 
mining causes ; they account for the great excess of fractures in males 
over those in females between youth and old age, and for their rarity 
in young children. 

The normal or physiological causes are those which have their 
origin in the position and functions of the different bones. The 
bones of the skull and chest are broken when the violence against 
which they are designed to protect the enclosed viscera is too great for 
their power of resistance ; the use of the arms in many occupations 
exposes them to fracturing violence, and they and the lower limbs are 
broken in falls all the more easily because of the contraction of the 
muscles by which they are stiffened to protect the body against the 
shock. In like manner the normal curves in single or associated bones 
— e. g., the clavicle and spinal column — which supply an elasticity 
that is protective of the viscera increase their liability to fracture. 

Interstitial atrophy of the bones, which is so common a senile change, 
is undoubtedly the cause of the greater relative frequency of fractures 
in the old ; and its agency becomes all the more apparent when the 
usual withdrawal of the aged from the occupations which most expose 
to fracture is taken into account. This atrophy consists in thinning of 
the cortex of the shafts and of the trabecular of the spongy portions 
and of the short bones, not in a relative increase of the lime salts in 
the bone tissue itself, as was long supposed. It is an actual diminution 
of the bone substance and a corresponding increase of the fat and other 
soft parts contained in it. In the old, and when not extreme, it may 
be classed as a normal predisposition to fracture, but when it appears 
prematurely or readies an extreme degree it must be deemed patholog- 
ical and classed witli other similar atrophies whose nature and eauses 
are not well understood. 

39 



40 FRACTURES. 

The inherited or early developed liability to fracture which has been 
observed in certain individuals and families who were in other respects 
normal is probably the result of a similar scantiness of the bone tissue. 
Of this inherited liability Gurlt gives three examples, extending in 
one over four generations, in the others over three. One of the patients 
suffered fourteen fractures, and another thirteen, before either reached 
the age of thirteen years. All united promptly. He gives also three 
cases of a congenital but not inherited liability to fracture in families. 
One girl suffered thirty-one fractures of the thigh, leg, and arm between 
the ages of three and fourteen years ; her sister had nine before she was 
six years old. Not infrequently individuals have developed in early 
or middle life a noticeable fragility of the bones without any other 
change that would indicate a general deterioration or disease. Thus, 
Biggs 1 reports a case of twenty-two fractures, all but one of the arm 
or thigh, between the ages of twenty and thirty years in a man who had 
suffered none before or after. 

Immediate or Determining Causes of Fractures. 

These are of two kinds: (1) External violence, and (2) muscular 
action, the latter exerted by muscles connected more or less directly 
with the bone that is broken. 

1. Fractures by External Violence. The division of these into two 
classes, of which one is called fractures by direct, the other fractures 
by indirect, violence is based upon clinical differences often of ex- 
treme importance, and not simply upon mechanical differences in the 
mode of transmission and in the effect of the applied force. This 
relieves us, therefore, from the necessity of examining the latter ques- 
tions with their many obscure factors and complex relations, and makes 
the definitions simple. A fracture by direct violence is one in which 
the bone is broken immediately under the point upon the surface where 
the fracturing force is exerted ; and a fracture by indirect violence is 
one in which the fracture takes place at a distance from that point. 
The most important clinical difference between the two varieties de- 
pends upon the injury to the overlying soft parts in the one case and 
the absence of such injury in the other. 

The skin is not always broken in fractures by direct violence, even 
when the vulnerant force has been great and the injury to the soft parts 
under the skin extensive, but it may have been so injured, even if it 
shows no marks of violence, that it will slough. On the other hand, 
the blow may break the skin at the point where it is received and pro- 
duce fracture indirectly at a greater or less distance, the bone yielding 
at its point of least resistance and not at that where the force is directly 
exerted. 

The fracturing force may be applied directly or indirectly to the bone, 
to crush or break it, or obliquely to its long axis, or as torsion, or as 
avulsion. Examples of the first are furnished by falls upon the feet 
with fracture of the calcaneum, gunshot wounds, and crushing of the 
lower end of the radius in a fall upon the hand ; of the second by most 

1 Biggs: Univ. of Penn. Bulletin, 1903, Ko. 12. 



ETIOLOGY. 41 

fractures of the shafts of long bones ; of the third by some fractures 
of the leg when the foot is fixed and the body turned forcibly about it ; 
and of the fourth by some fractures of the lower end of the humerus 
by forced abduction of the forearm, by some of the internal malleolus 
in eversion of the foot, and by some of the patella in forced flexion of the 
knee when its normal range of motion has been limited by previous 
injury. 

Indirect fractures are by far more common in long bones than in the 
short spongy ones, because of their proportions and functions. The 
principle of their production is that of the transmission of a force 
along a bone or set of bones made rigid by ligamentary attachments 
or muscular contraction in such manner that it is resolved into forces 
acting in two or more directions, one of which crosses the long axis 
of the bone and acts as if it had been applied directly at the point of 
least resistance in a transverse direction. The effect is greatly modi- 
fied by the anatomical structure and form of the bone, the attitude of 
the limb, the contraction of the muscles, and the direction of the blow. 
Thus, a fall upon the hand may break the bones of the forearm, the 
humerus, or the clavicle; a fall upon the foot may fracture the calca- 
neum by direct violence, or the bones of the leg, the thigh, or even 
the vertebral column or skull by indirect violence. 

The best example of the fracture of short bones by indirect violence 
is furnished by the spinal column, the bones of which, considered as a 
group, constitute a long bone with several curves, the forcible exag- 
geration of which produces fracture. 

2. Fractures by Muscular Action. Under this head are included 
only those fractures in which the rupturing force is exerted by the 
muscles alone, without the aid of any external violence. It is, of 
course, evident that, if an individual breaks his skull or a limb by 
running or striking against a solid object, the force that causes the 
fracture is developed by the action of his muscles; but the mechanism 
is the same as if he had fallen from a height, or as if his body was at 
rest and the object with which he has come into contact was in motion. 
And in many other cases the distinction is somewhat arbitrary and 
rather clinical than mechanical, for often in fracture by external vio- 
lence resistance to movement of the bone in the direction impelled by 
the external force is supplied by the muscles, and without that resist- 
ance fracture would not occur. The conditions are practically the same 
as if, the distal end of the limb being held stationary, the muscles were 
sharply contracted in an attempt to move it. Thus, a man holds his 
arm outstretched while another seeks to lower it by striking the fore- 
arm, and the humerus breaks below the insertion of the deltoid ; or a 
man pushes with his foot, the knee being partly flexed, his foot slips 
and the patella is broken by the tearing away of its lower portion in 
the sudden flexion of the knee, the upper part being held stationary bv 
the tense quadriceps. Strictly speaking, only those eases are considered 
to be fractures by muscular action in which the action is exerted directly 
by the muscles upon the bones to which they are attached (mediately 
or immediately), either as direct traction, as in fracture o\' the patella 



42 FRACTURES. 

or of the olecranon, or obliquely, or in torsion against resistance, or by 
sudden muscular arrest of the rapidly moving limb, as in throwing, or 
in striking or kicking at an object and missing it. 

Some authors have expressed the opinion that no bone can be broken 
by simple muscular contraction unless it has previously undergone 
some change that has diminished its strength; but this opinion must 
be looked upon as an attempt to explain away by an unfounded, or at 
least an unproved, assumption a difficulty which does not really exist. 
It is no more logical to claim that such a change has preceded every 
fracture by muscular action than it would be to make the same claim 
for fractures by external violence ; it can rest only upon the assump- 
tion that the power of resistance of a normal bone is superior to any 
force that a muscle or group of muscles can exert upon it, even under 
extreme and unusual circumstances; whereas, on the contrary, nature's 
precautions and adaptations are calculated upon the basis of the prob- 
able, not of the exceptional. Such a position may be taken with pro- 
priety concerning all fractures produced by slight causes in the old, 
the diseased, the cachectic, or in those who have suffered pain at the 
point of fracture for some time previous to the accident ; but it is 
entirely unsupported by proof in the rarer, but still sufficiently numer- 
ous, cases of the fracture of the shaft of a long bone produced by a 
violent effort in a healthy athletic man, and in the common ones of 
fracture of the patella. 

The effect of muscular action is manifested in all the degrees of 
varying importance between its relatively unimportant additions to 
the effects of external violence and those cases in which it is the sole 
agent of the fracture of a healthy bone. The intermediate degrees 
are presented by those fractures, usually of weakened bones, in which 
moderate muscular action has acted either alone or combined with 
slight external violence. In the first case, when the power of the 
muscle is exerted in the same direction as the external violence, it 
increases the fracturing force by just so much; and, by prolonging its 
effect after the fracture has been made, it also increases the displace- 
ment of the fragments and the laceration of the soft parts. The prin- 
cipal interest of the intermediate cases is connected with the cause of 
the exceptional fragility of the bone, and is considered in the following 
section — Spontaneous and Pathological Fractures. 

The commonest examples of fracture by muscular action alone are 
furnished by the patella ; other apophyses and tuberosities to which 
powerful muscles are attached— the olecranon, greater tuberosity of 
the humerus, coracoid, acromion — furnish them much more rarely. 

Of the long bones the humerus is the one most frequently broken 
in this manner; out of 85 cases of fracture of the limbs by muscular 
action collected by Gurlt, 1 57 were fractures of the humerus, 15 of the 
thigh, 8 of the leg, and 5 of the forearm. Ashurst 2 collected 81 cases 
of fracture of the humerus : 24 by torsion, 57 by a blow. The mech- 
anism seems in most cases to be the same as in indirect fracture ; in 
some the fracture takes place at the insertion of the muscle, and in 

1 Gurlt : Loc. cit., vol. i. p. 232. 2 Ashhurst: Univ. of Penn. Med. Bull., Feb. 1906. 



ETIOLOGY. 4:3 

others the elements are too complex and too conjectural to be explained 
theoretically. In a comparatively small number of cases the fracture 
has been caused by reflex spasms in limbs that had long been paralyzed 
or by the convulsions of epilepsy or tetanus, but usually the cause is a 
violent voluntary muscular effort to avoid a fall, to throw a stone, or to 
lift a heavy object. The following cases taken from Gurlt illustrate the 
different forms and the methods by which they may be produced. It 
must be remembered that fractures produced during convulsions need 
to be closely examined in order not to overlook the possible addition of 
external violence by a fall from the bed or by a blow. 

In a negro boy, twelve or thirteen years of age, affected with teta- 
nus, both thigh bones were broken " at the neck," possibly just below 
the trochanter, by the contraction of the muscles, and the fragments 
forced through the skin on the outer side of the limb. 

An athletic man, thirty-four years old, accustomed to lift heavy 
weights, broke his humerus with an audible snap, just below the inser- 
tion of the deltoid, by the effort made, on a wager, to throw a stone 
weighing about two ounces the distance of a hundred yards. Recovery 
in six weeks. 

Gurlt gives also 11 cases (Ashhurst, loc. cit., 24) in which the humerus 
was broken during that trial of strength in which two men place their 
elbows upon a table, clasp hands with the forearms parallel and vertical, 
and strive to force each other's hand backward. 

Fractures of the femur may occur at any point of the shaft, and in the 
recorded cases have been the result of an attempt to kick, to avoid a fall, 
or to rise from the ground on one foot, or of cramps, excited in one case 
by drawing on a tight boot and in another by turning in bed. 

A man, thirty-six to thirty-eight years old, of middle size and great 
muscular power, broke his thigh at the junction of its upper and middle 
thirds by kicking at and missing his servant. 

Van Oven described before the Royal Medical and Surgical Society 
a fracture of the thigh sustained by himself. He was fifty-six years 
old, healthy and strong, and free from taint of cancer, scrofula, syph- 
ilis, etc. He was awakened by a sharp, cramp-like pain above the 
knee, and as he felt the part with his hand, and noticed that the muscle 
was tense, he heard a snap, followed by relaxation of the muscle, crepi- 
tus, "and diminution of the pain. Examination showed a transverse 
fracture of the femur three inches above the knee. Complete recovery 
in four months. 

A cavalryman, twenty-nine years old, while trying to rise from a 
sitting posture on the ground without the aid of his hands, broke his 
right thigh at its middle. 

Gurlt' s eight cases of fracture of the leg comprise four of both bones, 
one of the tibia, and three of the fibula alone, the latter being fractures 
at the upper end of the bone by the contraction of the biceps. 

A small, rather corpulent woman, forty-five years old, slipped on 
the left foot while descending some steps, made a violent effort with 
the right leg to avoid a fall, felt at once a severe pain in the latter, and 
fell in a sitting posture. An immediate examination showed a fracture 
of both bones at the middle of the leg. 



44 FRACTURES. 

A woman, fifty-two years old, mistook a door leading into the cellar 
for one opening into a closet, and. recognizing the mistake as she put 
her right foot forward, drew herself instinctively backward, and felt 
at the same moment something snap in her left leg, upon which the 
weight of her body rested. She fell and rolled down the steps. A 
fracture of the left fibula just below its head was found. 

Fracture of either or both bones of the forearm has been caused by 
the wringing of wet clothes and in shovelling. A healthy girl, eighteen 
years old, while wringing clothes, felt a sudden sharp pain on the inner 
side of the forearm above the wrist. Three days afterward a fracture 
of the ulna, two and one-half inches above the wrist, was recognized. 

A woman, thirty years old, broke the radius in its lower third with 
severe pain while wringing two heavy towels. 

Fractures of the clavicle have been caused by the effort of raising a 
heavy object, shovelling, and striking backward or with a whip. 

Fractures of one or more ribs are not infrequently caused by violent 
coughing, especially in the consumptive. The sternum has been broken 
in four recorded cases by the violent straining and bending backward 
of the body during the expulsive efforts of parturition, and there are 
several cases of fracture of the cervical vertebrae by muscular action 
alone, and of the scapula. 

Hilton reports the case of a man who had broken a rib by muscular 
action while trying to mount a spirited horse. 

A primipara, twenty-four years old, taken in labor, sought to hasten 
delivery by forcible expulsive efforts, bending backward and resting 
on her elbows and heels ; she felt a sudden sharp pain and a snap in the 
middle of the breast, and said at once that something had broken there. 
She died of peritonitis, and at the autopsy a transverse fracture of the 
sternum was found, one and one-half lines above the junction of its 
body and the manubrium. 

A soldier dived into a river, and, not reappearing, was sought for 
and brought out. His body showed no trace of external violence, but 
there was paralysis of all the limbs, loss of sensation, pain at the pos- 
terior and lower parts of the neck, priapism, frequent desire to urinate. 
He said that as he dived he saw the water was too shallow, and in the 
effort to avoid striking against the bottom he jerked his head sharply 
backward and at once lost consciousness. He died the same night, and 
the autopsy showed a transverse fracture of the body of the fifth cer- 
vical vertebra a little below its centre. A number of similar cases 
have been reported. 

A servant engaged in preparing a lamp raised his arm quickly to 
arrest the action of an escaping spring and felt something give way in 
it. The arm fell powerless by his side, and the greater portion of the 
acromion was found to have been broken off. 

I have seen two fractures of the coracoid process by forcible con- 
traction of the muscles of the arm. 



ETIOLOGY. 45 

Spontaneous and Pathological Fractures. 

The term spontaneous is used to indicate that the violence, external 
or muscular, which has produced the fracture is much less than that 
commonly observed in that form ; and the term pathological to indi- 
cate a preceding abnormal change in the fractured bone by which 
its strength has been diminished. It has become common to use the 
terms interchangeably, because the slight violence indicated by the 
first is efficient to fracture only when the change indicated by the 
second is present. 

It is noteworthy that the pain accompanying or following the frac- 
ture is often very slight • fractures of ribs, and even some of the limbs, 
have passed unrecognized until the autopsy. The pathological condi- 
tion known as general atrophy or rarefaction of the bone, or osteopo- 
rosis, and which has been referred to as senile atrophy, may appear 
prematurely or may have its origin in other causes than senility, such 
as paralysis, locomotor ataxia, diabetes, pregnancy, and osteomalacia. 
It is worthy of note that in not a small proportion of cases union takes 
place promptly. In most of the cases which furnish autopsies the bones 
are found softened and reduced to a shell by absorption from within, 
and in some of the cases suppuration has taken place at the fracture. 

It has been noted by Bouchard and by Verneuil and Verchere that 
spontaneous fracture occasionally happens in the diabetic, and that the 
urine shows the presence not only of sugar but also of phosphoric acid 
in quantities that suggest its origin in a decalcification of the bones. 
These observations have been confirmed by Isch-Wall (quoted by 
Ricard), who also found the phosphoric acid present in some patients 
affected with cancer. In nine cases of spontaneous fracture in the 
diabetic reported by Verchere union was greatly delayed. 

The following cases represent different varieties : 

A woman, seventy-two years old, had both thighs broken by kneel- 
ing in church, and the humerus by the efforts of bystanders to lift her 
up. Another broke her clavicle by putting her arm about the nurse's 
neck and trying to turn herself in bed (Gurlt). 

A woman, forty-five years old, the mother of two children, suffered 
a great deal of pain in her bones after the birth of her second child, 
and became so helpless that she could not get into or out of bed with- 
out aid. She broke each thigh below the trochanter by stumbling 
against the bedpost in one case and by turning in bed in the other. 
Both united with marked angular displacement, and at the autopsy the 
bones of the thigh and pelvis were found to be so light that they floated 
in water and could be crushed by pressure with the finger. The cor- 
tical layer of the femur was as thin as an egg-shell, the medullary 
canal enlarged, traversed here and there by delicate plates of bone, and 
filled with a grumous, semifluid mixture of blood and marrow (Gurlt). 

A man, sixty years old, broke his femur in the middle third by 
stumbling, without falling. He died a fortnight later, and 1 found an 
enormous calculus in eaeli kidney. 

Saviard saw in 1690 a woman, about thirty years old. who had suf- 



4(3 FRACTURES. 

fered for four months with severe pains throughout the body, increased 
by movements, and without fever. Three months later she had become 
bedridden, and her bones had become so friable that most of them were 
broken, and she could not be moved without causing a new fracture. 
She lived ten months in this condition, and the autopsy showed frac- 
tures of almost every bone in her body. The structure of the bones 
was so delicate that they could not be pressed between the fingers with- 
out breaking into small pieces ; the marrow was red, the muscles pale, 
the joints and cartilages unchanged. 

In a case under my care the tibia appeared to have been weakened 
by an osteitis set up by a blow and a wound of the soft parts. The 
wound healed in three weeks ; a fortnight later the patient returned 
with a compound fracture of the leg at the scar, caused by stepping 
down a distance of two feet. The bone could be plainly seen and was 
rarefied. Prompt recovery. 

A similar friability is also found in some cases of old unreduced 
dislocation, due, it is supposed, to lack of use. The condition was 
shown by direct examination in a case of subcoracoid dislocation of six 
weeks' standing, in which Guerin l tore oif the forearm in an attempt 
to reduce. The ends of the bones were rarefied and soft, and the mus- 
cles softened and brown. The autopsy showed no change in the other 
portions of the body. 

It seems probable, however, that in most cases in which fracture has 
occurred during an attempt to reduce a dislocation, and in which un- 
usual fragility has been alleged in explanation, the force exerted upon 
the bone has been greater than the surgeon supposed, because of the 
leverage employed, especially in rotation of the limb. 

Disease of the Nerve-centres. In 1842 Davey called attention to the 
facility with which fracture sometimes occurred in lunatics, especially 
in those w r ho were also paralytic, and the observation has been abun- 
dantly confirmed, Brims having collected more than sixty reported 
cases. 2 Weir Mitchell 3 was the first to call attention to the frequency 
of fractures in those affected with locomotor ataxia, and suggested that 
the cause might lie in an impairment of the nutrition, and consequently 
of the strength, of the bone dependent upon the disease of the cord. 
Shortly afterward Charcot 4 published a remarkable case of multiple 
fractures and dislocations in an ataxic woman, and Bruns 5 followed 
with a paper upon the subject, based upon thirty cases reported within 
a few years. He finds that the fractures are usually multiple, from 
two to six in number, and are most common in the lower limb, espe- 
cially in the femur ; the frequency is equal in the different bones of the 
upper extremity — clavicle, humerus, and forearm. Repair takes place 
in the usual time. 

The accident seems to occur more frequently in the earlier than in 

1 Guerin: Bull, de la Soc. de Chir., 1864, vol. v., pp. 121 and 131. 

2 See also Baum : Deutsche Zeitschrift fur Chir. Vol. 99, p. 1, for 120 cases. 

3 Weir Mitchell: American Journal of the Medical Sciences, July, 1873, p. 113. 
4 Charcot: Arch, de Phys., 1874, p. 166. 

5 Bruns : Berlin, klin. Wochenschrift, 1882, p. 164. 



ETIOLOGY, 47 

the later stages of the nervous disease, and the predisposing condition 
is a rarefaction of the bone marked' by great absorption of the compact 
tissue, increase of fat, and loss of inorganic matter. A very remark- 
able instance of the earliness of this change is given by Tillmann 1 in 
the report of three cases of spiral fracture of the shaft of the femur 
caused by the effort made in drawing off a shoe. The patients showed 
nothing abnormal at the time, but when examined three and half, five, 
and eight years later, respectively, locomotor ataxia existed. 

Rachitis. Friability due to rachitis is found only in childhood, for 
the disease is one which involves the bones only during their period of 
growth, and consists essentially in the prolongation and exaggeration 
of the embryonal or developmental condition of the shaft, in conse- 
quence of which its strength and the firmness of its union with the 
epiphyses are diminished. 

Union after fracture takes place rather more slowly than in normal 
bone, and sometimes fails entirely. The callus is usually large, but, 
as it is composed of the same soft embryonal tissue whose excess is the 
pathological feature of the disease, it is lacking in firmness. 

Syphilis, Mercurialism, and Rheumatism. Syphilis affects the organ- 
ism in so many and so varied forms, and causes such serious bone 
lesions in its later stages, that it is not strange that both physicians and 
patients have been inclined to attribute to it fractures produced by 
slight causes whenever the patient was or had been affected by it. 
And in like manner those who saw in mercury the cause of the bone 
lesions of syphilis attributed the fractures to the use of that drug. 

When we remember what multitudes of people have contracted 
syphilis, how numerous those in whom it has caused grave lesions of 
the bones, and on the other hand how few are the cases, excluding sep- 
aration of the epiphyses in the new-born, in which it can even be sus- 
pected as a predisposing cause of fracture, it is evident that it can have 
but little influence in this direction ; and an examination of the alleged 
cases shows very frequently a coexisting constitutional weakness or a 
cachexia not always to be attributed to the specific disease which 
creates a close resemblance between these cases and those in which the 
friability of the bone is due to a premature or exaggerated senile 
atrophy. Yet it seems strange that the development of a gumma in 
the shaft of a long bone, with the consequent destruction of tissue, 
does not more often lead to fracture. 

Gurlt's fifteen syphilitic cases include five in which the fracture was 
preceded by severe pain, more or less prolonged, in the broken bone, 
and these might be deemed demonstrative of the influence of syphilis 
did we not possess other similar cases in which the syphilitic complica- 
tion does not exist. Malgaigne, indeed, speaks of local inflammation 
of the bone as a frequent and too much neglected predisposing cause of 
fracture, adding : " I give this name, conjectu rally, to an affection 
which manifests itself by dull pains attributed by the patient to some 
contusion or to rheumatism, rarely sufficient to cause a general reaction, 
and attracting but little attention until some slight cause produces frac- 

1 Tillmann: Berlin, klin. Wochenschrift, 1896, No. 35. 

'-'Malgaigne: Loe. cit., p. 22. 



48 FRACTURES. 

ture at the point it occupies." There is a striking similarity between 
the cases he cites and Gurlt's syphilitic cases. 

There seems to be no reason to suppose that mercury has any direct 
action upon the bones rendering them more liable to fracture, and the 
most that can be claimed is that its excessive, unskilful use will cause 
a deterioration of the health, which may result in an atrophy of the 
bones similar to that found in old age. 

Cancer and Sarcoma. There are two ways, apparently, in which the 
development of a malignant tumor may lead to fracture : either the 
tumor may occupy the bone itself, primarily or secondarily, and destroy 
it to such an extent that the slightest force is sufficient to fracture it, 
or the presence of the tumor elsewhere may induce a cachexia which 
results in atrophy of the bones. The following cases are quoted in 
illustration : 

Louis * was called to see a nun, sixty years old, whose arm had been 
broken by the efforts of a coachman to help her into a carriage. Union 
did not take place, and six months later, while seated in a chair, she 
broke her femur by letting her hand fall upon it. Louis, seeking the 
cause of this fragility, then learned that the patient had an ulcerated 
cancer of the breast. 

A woman, 2 forty years old, who had a cancer of the breast for some 
time, with well-marked cachexia, broke her right femur in the lower 
third by rising from a chair. She was taken to the hospital, and there 
the other femur was broken by the interne as he was preparing to 
apply a bandage to the first. She died the same night, and at the 
autopsy cancerous masses were found in the spongy tissue and in the 
medullary canal at the points of fracture and elsewhere, also in the 
vertebra? and cranial bones. 

I have now under treatment a woman thirty-one years old who broke 
her left femur in the upper third by stumbling, without falling. For 
two years she has had a carcinoma of the left breast, unulcerated but 
involving the skin. Two months later there was a large mass at the 
seat of fracture, and on moving the limb crackling (apparently the 
breaking of small pieces of bone) could be plainly felt. Now, a month 
later, there seems to be fairly firm union. 

In thirty-two cases collected by Gurlt in which the position of the 
primary tumor is noted, it occupied the mammary gland twenty-six 
times (once in a man); and of the entire thirty-eight cases thirty-five 
were women. As a rule, too, the affection was of long standing; in 
many of the cases the tumor had returned after removal, and in nine 
it had ulcerated. The humerus and femur were almost exclusively 
affected, but very unequally — twenty-six fractures of the femur and 
seven of the humerus. Severe localized pain in the bone preceded the 
fracture in a number of cases. 

.Reunion took place in one-fourth of the cases, and in at least three 
of these there was cancerous degeneration of the bone at the seat of 
fracture. In most of the remaining twenty-eight cases death, due to 

1 Malgaigne : Loc. cit., vol. i. p. 14 

2 Cruveilhier : Anat. Path., Livraison xx, PL 1, Fig. 4. 



ETIOLOGY. V.) 

the progress of the disease, followed so soon after the fracture that the 
bones had not time to unite, even if they were capable of doing so. 

Hydatid and Other Cysts. There are a few instances on record in 
which the unsuspected development of a hydatid cyst within a bone 
has resulted in its fracture by slight violence at the point occupied by 
the cyst ; and others in which a similar result has been produced by 
the occurrence of a cystic degeneration of unspecified character within 
the bone. These causes act by direct absorption of the cortical layer 
of the bone, and their action is purely local. 

Osteomyelitis favors fracture by partial destruction of the bone, but 
as this effect is accompanied by a rapid and often very bulky new- 
formation which makes good the loss, fractures are but infrequently 
observed except in the course of operations undertaken for the cure of 
the disease which require much cutting away of the new bone. I 
have seen several such ; their importance is slight, for there is usually 
but little displacement, and repair takes place within the usual time. 

Intra-uterine Fractures and Fractures During Delivery. 

Fracture of a limb of the child during its delivery through the natural 
passages of the mother is not very infrequent and is usually the result 
of manual or instrumental interference. Such fractures belong to the 
class of fractures by external violence, and present no features of 
special interest ; but there are others in which the fracture is caused 
by the expulsive efforts of the mother alone. An arm or a leg is 
engaged between the body of the child and the rigid parts of the 
mother, and the humerus or the femur is broken, sometimes with an 
audible snap, as the child is forced through the passage. 

Fractures within the uterus have been caused in a few cases by a 
bullet or sharp instrument that has at the same time perforated the 
abdominal wall of the mother. 

The possibility of the occurrence of fracture within the uterus as 
the result of external violence without perforation of the abdomen of 
the mother, or, in some cases, of unknown causes, has been proved by 
the birth of children presenting fractures of different bones in various 
stages of repair. It is not always easy to say, when a child is born 
with a fracture, whether it was caused during delivery or at an earlier 
period, or whether it was due to external violence or to the contractions 
of the uterus. And, further, it is not always possible to say whether 
an apparent fracture is actually one or only a malformation, a defect 
of ossification or of development, or a separation of the epiphysis due 
to syphilis. Gurlt collected eight cases in which the causal relation 
between an injury received by the mother during pregnancy and the 
fracture observed in the child seemed to him to be clearly demon- 
strated, and twenty-five others in which more or less doubt existed as 
to the cause of the fracture or the character of the lesion. The injury 
in the first eight cases was either a fall from a height or a violent blow 
upon the abdomen ; and the bones broken were those of the thigh, leg, 
arm, and forearm, and the clavicle. 
4 



50 . FRACTURES. 

The other group includes some in which an undoubted fracture 
existed, but with no history of external violence, and some in which 
the coexistence of malformations threw some doubt upon the character 
of the supposed fracture, and others in which the fractures were so 
numerous and so symmetrical that they must have depended upon some 
general cause, syphilis or rachitis, acting possibly upon the epiphyseal 
cartilages. 



CHAPTEE IV. 

EARLY SYMPTOMS AND DIAGNOSIS. 

The symptoms produced by a fracture are divided into two groups : 
the objective or positive, those which can be directly observed by the 
surgeon, and the subjective or rational, those for his knowledge of which 
he has to depend more or less completely upon the statements of the 
patient. The former include deformity of the limb or part, abnormal 
mobility at the point of fracture, and crepitus. The second group 
includes loss of function, pain, and history of the case and of the 
patient. 

Objective Signs. 

Deformity. This term is here employed in its widest sense, to include 
changes in the relations of the fragments of the bones to each other 
and the modifications in the appearance of the limb or part of the body 
produced by those changes, by the effusion of blood, and by the later 
inflammatory processes. 

The changes in the relations of the fragments to each other have 
been described in detail under Displacements. Many of them are so 
marked that they are recognizable by simple inspection of the part, 
while others are brought to light only by careful palpation and by meas- 
urements compared with those of the opposite limb. These measure- 
ments are used in practice only to recognize displacements by which a 
limb is shortened or the diameters of an articular extremity modified. 
In a few places practically normal relations exist which may take the 
place of comparison with the opposite limb : such are those of the great 
trochanter of the femur to a line drawn from the tuberosity of the 
ischium to the anterior superior spine of the ilium, and those of the 
styloid process of the radius to that of the ulna, both of which may 
be used with confidence in cases of fracture of the neck of the femur 
or of the lower extremity of the radius respectively. 

The chief difficulty in employing mensuration is that of finding 
well-defined points upon the skeleton between which the measurements 
can be made. Those employed in fractures are bony prominences or 
edges sufficiently near the surface to be clearly felt, but as they are all 
more or less rounded, absolute accuracy in measuring the distance is 
impossible. 

Another cause of uncertainty or of error lies in the normal asym- 
metry, the difference not due to traumatism or disease, which has been 
found occasionally to exist, and which sometimes is very notable, as 
much as an inch and a half in the lower limbs. 



52 FRACTURES. 

Other sources of difficulty and error are found in the swelling of the 
soft parts, which may prevent the tape from being drawn straight, and 
in the varying angles between the axis of the limb and the line of 
measurement. The first is not likely to be great or to be overlooked ; 
but the latter is a frequent source of error. It is rare that fhe two 
fixed points between which the measurement is made are both upon 
the limb or the bone whose length is in question ; one of them is usually 
upon the trunk, and lies at a certain distance from the centre of motion 
of the limb. Consequently, any change in the position of the limb 
changes the distance between the two points that have been chosen. 
For example, in measuring the length of the lower limb the points 
taken are the anterior superior spine of the ilium and the tip of the 
malleolus ; the former lies several inches away from the centre of the 
hip-joint, and when the limb is in abduction the distance between the 
chosen points is less than when the limb is parallel to the long axis of 
the body. If a comparison is to be made between the two limbs, it is 
essential that their position with reference to the pelvis should be the 
same, and, therefore, care must be taken that the ankles are equidistant 
from a line drawn between them at right angles to and from the centre 
of another connecting the two anterior iliac spines. 

Similar difficulties and uncertainties exist in transverse and periph- 
eral measurements. The swelling of the soft parts not only increases 
the bulk of the limb, but it also obscures the bony prominences and 
places them at a greater distance below the surface, so that an accurate 
measurement of the distance between points on the opposite sides of a 
bone is practically impossible. For this and for rotatory and angular 
displacements the trained eye, aided by careful and minute considera- 
tion and palpation of the anatomical landmarks and comparison with 
the opposite limb, is the best guide. 

The appearance of the limb will be still further modified by swell- 
ing due to extravasated blood and inflammatory exudate, and some- 
times to the shortening of the limb, which increases its transverse 
diameters. 

Ecchymosis is a symptom that is rarely absent, although its appear- 
ance may be delayed for several days. It is most marked and most 
extensive in the old. The blood which escapes from the broken bone 
and the adjoining parts makes its way along the muscular planes, and 
first appears under the surface at some distance from the fracture. Its 
appearance at certain points creates a strong presumption of fracture 
— e. g., beneath the malleoli in Pott's fracture — and the same interfer- 
ence is measurably justified whenever an ecchymosis appears upon a 
limb that has not been directly contused. 

Large blebs, the serum of which is often dark, frequently appear 
upon the leg a day or two after its fracture ; less frequently upon 
other limbs. The cause of their production is not known. 

In fractures communicating with joints a characteristic deformity is 
caused by the filling of the cavity of the joint with blood or an inflam- 
matory effusion, the situation of which is shown by its limitation 
within the boundaries of the articular capsule. 

Abnormal Mobility. Mobility appearing after injury at a point in a 



EARLY SYMPTOMS AND DIAGNOSIS. 53 

bone where it did not previously exist, and permitting the bone to be 
bent at an angle, or a portion of it to be moved while the other por- 
tion remains at rest, is pathognomonic of fracture, but it is not always 
present or recognizable, for the fracture may be incomplete or too near 
a joint, or one of the fragments may be too small or too deeply placed 
to be grasped. In fracture of the ribs, sternum, or fibula the elasticity 
of the bone may deceive if not taken into consideration, or raise a 
doubt if it is. 

The manipulations employed for the detection of abnormal mobility 
vary with the seat of fracture and the kind of mobility which is sought 
to be produced. In fracture of the shaft of a long bone the surgeon 
seeks first to produce an angular displacement by passing his hand 
under the limb at the supposed seat of fracture and gently raising it, 
or by grasping the two extremities of the bone firmly and moving the 
lower one slightly from side to side while the upper one is held sta- 
tionary. Or he may grasp the limb with both hands close to the 
fracture, and produce transverse displacement by moving the fragments 
bodily in opposite directions. In fracture of the shaft of the fibula, 
radius, or ulna lateral mobility may be detected by grasping the limb 
with both hands above and below the fracture, and then making press- 
ure alternately against the bone. 

In fracture of the upper portion of the shaft of the femur or of the 
neck of the humerus or of the upper end of the tibia, where a lateral 
or angular mobility cannot be easily recognized, recourse may be had 
to slight rotatory movements of the lower portions of the limb, while 
the upper portion is so held that its bony prominences can be distinctly 
felt by the fingers. Abnormal mobility is then recognized by the 
failure of the manipulation to transmit the rotatory movements to the 
upper fragment. It is essential that the communicated movements 
should be slight, for otherwise the attachments of the soft parts or the 
interlocking of the fragments may prevent the success of the manoeuvre, 
which, moreover, for obvious reasons, must fail in partial or impacted 
fractures. 

In fracture of either condyle of the femur or humerus, or in frac- 
ture of an apophysis, the surgeon must try to grasp the fragment 
firmly and move it in the direction of the plane of fracture. 

It is sometimes possible to give a fragment a tipping or see-saw 
motion ; thus, by pressing the tip of the external malleolus inward, 
when the fibula has been broken just above the ankle, the upper end 
of the lower fragment may sometimes be felt to move outward. In 
this manipulation the sliding of the skin is liable to be mistaken for 
movement of the bone, and should be guarded against by pressing the 
fingers toward each other so as to relax the skin between them. 

Crepitus. This is the sound produced, or the sensation communi- 
cated to the hand of the surgeon, by the friction of the fragments of a 
broken bone against each other, [t is as pathognomonic of fracture 
as is abnormal mobility, and these two signs usually eoexist. The 
sensation is not the same in all cases; it may be the sharp click of two 
hard points or edges, or a dull, muffled contact, or the crackling and 
grating of multiple fragments and broad surfaces. Some ot' its forms 



54 FRACTURES. 

are practically identical with the friction sounds obtained by the move- 
ment of joints whose surfaces are altered by disease, and although it- 
is usual to speak of a recognizable difference in the quality of these sen- 
sations, the one being called hard or rough, the other soft or smooth, 
the diagnosis in cases of doubt must depend upon circumstances other 
than this difference. 

Crepitus is perceived through the hand rather than the ear, although 
sometimes it is audible to bystanders not in contact with the patient. 
It is to be sought by the same methods as abnormal mobility, and also 
in the ribs and flat bones by placing the palm of the hand over the 
supposed seat of fracture and pressing gently in various directions. 
Direct auscultation is sometimes employed, especially in fracture of 
the ribs or sternum. 

Crepitus cannot always be produced when there is a fracture, for 
its production is conditioned upon the contact and, in a measure, the 
character, of the broken surfaces. If the fragments are completely 
separated, if a piece of muscle or fascia is interposed between them, or 
if they have become covered with granulations, their movements may 
not cause crepitus, and it is a common experience that the manipula- 
tion which produces it at one moment fails to produce it at the next. 

Auscultatory percussion, the stethoscope being moved from one frag- 
ment to the other while percussion is made upon the first, will some- 
times give a marked change in the sound as the line of fracture is 
crossed ; but it is rarely significant, except in cases in which the diag- 
nosis can be made by other means. 

Conditions giving rise to sensations that may be mistaken for crep- 
itus are : Roughness of neighboring joints, inflammation of the sheaths 
of tendons or of bursa?, and the crackling of coagulated blood. 

Roentgen Rays. — In obscure cases, in fractures of the small bones, 
and to determine details in those in the neighborhood of or directly 
involving joints, the z-rays may be of use and sometimes of great value. 
Errors of interpretation are, however, frequent. It must be borne in 
mind that the skiagram is the reproduction only of a shadow, and that 
the apparent modeling of the surface of the bone shown in it is the 
result of differences of opacity and is often misleading. The elements 
of the shadow are distorted by differences in the relative distances of 
the various parts from the plate and in the angle of the rays, and 
because of the absence of perspective these distances are not indicated. 
There are many elements of error in a skiagram, many possibilities of 
misinterpretation, which must be controlled by experience in the use of 
the rays and by digital examination of the part. I have recently seen 
a case clinically diagnosticated as fracture of the upper third of the 
femur, but the skiagram of which was thought by all to show a fracture 
at the base of the neck. The autopsy proved the correctness of the 
clinical opinion. The skiagraphic error was due to tilting of the upper 
fragment. An additional difficulty is caused in children by the per- 
meability of cartilage to the rays, in consequence of which large gaps 
corresponding to the cartilaginous epiphyses appear at the joints. Ex- 
cept for well-defined changes in outline of a single bone a skiagram can- 
not safely be taken as proof of all it seems to show, but needs to be in- 
terpreted by the aid of clinical findings and of considerable experience 



EARLY SYMPTOMS AND DIAGNOSIS. 55 

in its use. Particularly, I think, do we need to be upon our guard 
against assuming that dark lines across spongy bone always indicate 
lines of fracture. Stereoscopic views are, of course, more trustworthy 
than single ones, but they are not often available. 

Subjective or Rational Symptoms. 

Loss of function of the limb or part involved is a common result of 
fracture, and is due either to mechanical causes, such as the breaking 
of the lever through which the muscles act, or to the inhibitory effect 
of pain or the fear of pain. As pain due to other causes may have 
the same effect, and as the loss after some fractures, even of the main 
bone of a limb, may be at first slight, the presence or the absence of 
the symptom is only suggestive, not indicative, of the presence or 
absence of fracture. In most cases of fracture of a long bone the limb 
is practically helpless, but from time to time we meet with patients 
who can move it with some freedom or who can walk with a broken 
ankle, leg, or even thigh. 

Pain, spontaneous or on pressure upon, or movement of, the broken 
bone, is a constant accompaniment of fracture. Spontaneous pain 
when the part is at rest is usually slight, not distinctly limited to the 
seat of injury, and not significant ; but localized pain on pressure, on 
movement of the bone, and on pressing the fragments together is a 
valuable symptom, and in some cases the most positive one that can be 
obtained, and sufficient in itself for a diagnosis. It is to be sought for 
by pressure with the tip of the finger along the line of the bone, by 
pressing one end of the bone toward the other, or, more rarely, by 
gentle lateral or rotatory movements communicated to the lower por- 
tion of the limb while the upper is fixed, or by making the patient 
contract a muscle attached to the bone while its movement is opposed, 
as in fracture of the calcaneum or olecranon. It is of great diagnostic 
importance in absence of the positive signs, and is therefore specially 
valuable in many fractures near the end of a bone and in those of the 
metacarpals and metatarsals and ribs, and its absence is often a positive 
means of excluding fracture. 

The absence of pain on handling an important fracture, such as one 
of the leg or thigh, deserves attention as possibly indicative of central 
nervous disease or of commencing delirium tremens. 

The history, with reference to diagnosis, includes earlier injuries which 
may have modified the form of the limb, the nature of the accident, 
and the manner in which the force was applied, the interference with 
function, and occasionally the snap heard at the time and the distortion 
of the limb observed. A knowledge of the manner in which the vio- 
lence was applied is sometimes of value in determining obscure points, 
and, in the absence of positive information, indications may be gathered 
from the position of contusions or of stains made by contact with the 
ground. The account given by the patient must always be received 
with distrust, because of his preoccupation by other circumstances at 
the moment of the accident and of the tendency to substitute inference 
for observation. 

Such are the facts upon which the diagnosis is made. They are not 



56 FRACTURES. 

all present in every case, and it is never necessary to seek for them 
all ; deformity, abnormal mobility, and crepitus are alone absolutely 
pathognomonic, but in not a few fractures none of these can be recog- 
nized by manipulations that are not unduly severe, and the diagnosis 
must be made upon the history and localized pain. It is important 
that this should be borne in mind, for many a fracture has been over- 
looked because crepitus could not be got. The character of the injury 
is sometimes so apparent that it can be recognized at a glance ; in 
others so obscure that even the most careful and experienced observer 
may remain in doubt. In most cases the examination should be made 
systematically and thoroughly, beginning with the history and follow- 
ing with an investigation of the interference with function, the pain, 
the deformity, and the abnormal mobility and crepitus in that order. 

The clothing should be removed from the injured part, and in doubt- 
ful cases also from the opposite limb. After having noted such changes 
in appearance as are easily recognizable, the surgeon makes gentle press- 
ure with his fingers along the limb in search of the point of maximum 
tenderness and of irregularity of outline if the bone is subcutaneous, 
and when that has been found he seeks evidence of abnormal mobility 
at that point by one of the manipulations above mentioned. If the 
search is successful the diagnosis is made. If not, or if the injury is 
at a point where abnormal mobility is not recognizable, the surgeon 
seeks for such deformity as is likely to exist after such a fracture as is 
suspected, first inquiring whether the region has been previously 
injured, in order that he may not mistake an old deformity for a fresh 
one, and the pain of a sprain for that of a fracture. 

If neither abnormal mobility nor deformity can be recognized he 
tests for local pain by pressure in the long axis of the bone or by the 
action of attached muscles, and accepts pain thus aroused as indicative 
of the presence of a variety of fracture which may not give the signs 
that are lacking. 

If doubt still remains as to the existence of a fracture, and if the 
search for signs is hampered by the pain that the necessary manipula- 
tions cause, or if, a fracture having been proved, it is necessary to 
determine its details, he employs an anaesthetic after having made his 
preparations to utilize the anaesthesia for the reduction of displacements 
and the application of a dressing, or he resorts to the .T-rays. 

The compound character of a fracture is easily determined. In 
fractures by indirect violence the wound in the skin, close to the seat 
of fracture, is usually small and bleeds much more freely than a simple 
wound of the skin would ; in fractures by direct violence the tegu- 
mentary wound is usually large and ragged, and the broken ends of 
the bones can be seen or felt through it. It is not necessary positively 
to determine the existence of direct communication between the frac- 
ture and the external wound; the coexistence of the two is sufficient 
to make imperative the employment of every precaution against infec- 
tion that would be called for if such communication were known to 
exist. If the wound is explored at all, it should be done only as a 
part of the treatment, and with strict asepsis, not merely as a diagnos- 
tic measure. 



CHAPTER V. 

THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 

Anatomo-pathological Processes. 

The Callus. Bone is one of those tissues whose cicatrices are com- 
posed of a substance closely resembling, or identical with, the original 
tissue. The process of repair after fracture is fundamentally the same 
as that after other forms of injury, and its histological phenomena, 
like those of repair of other tissues, are those of normal growth and 
exaggerated nutrition. It begins with the enlargement and multipli- 
cation of the cells of the periosteum, marrow, Haversian canals, and 
lacunae; this multiplication produces a mass of granulations which fill 
the gap between the fragments and are transformed into bone, some- 
times directly, sometimes after having passed through a cartilaginous 
stage. This mass of new bone, at first spongy in its structure — that 
is, composed of irregular lamellae or plates circumscribing relatively 
large lacunae filled with bloodvessels and medullary elements — becomes 
firmer and more compact in some portions by increase in thickness of 
the lamella and consequent reduction in size of the lacunae — the pro- 
cess known as " condensing osteitis," and observed constantly in the 
foetus as well as in many pathological conditions — and becomes thinner 
and weaker in other portions until it finally disappears by the con- 
verse process, diminution of the lamellae through their absorption by 
the medullary elements of the lacunae, " rarefying osteitis," another 
stage of productive or simple osteitis and also found in the normal 
development of bone and in pathological conditions. The variations 
depend upon differences in the degree of the injury or in the position 
of the fragments, which require disproportionate amounts of work to 
be done by the different parts. The details of the process will appear 
upon examination of the manner in which it is carried on after simple 
fracture of the shaft of a long bone, an example which has the advan- 
tage of illustrating the behavior of all the different elements and of 
being both more complete and more open to experimental study than 
fractures of short bones or of the spongy extremities of long ones. 

When a fracture takes place the cylindrical shell is broken along an 
irregular line and probably always with the production of splinters of 
greater or less size. The periosteum is usually torn, but the extent of 
its rupture has probably been largely overestimated even when there 
is much displacement of the fragments. Oilier 1 was the first to call 
especial attention to the preservation of its continuity at some part of 
the periphery of the bone and to the fact that when a lateral or longi- 
tudinal displacement has occurred the membrane is stripped partly 

1 Oilier: Traite do la Regeneration des Os. 



58 FRACTURES. 

off one fragment, but without having its continuity broken, and thus 
forms a band uniting the two fragments. To this band he gave the 
name of " periosteal bridge." Other portions, also, which do not 
preserve their continuity with the rest, are doubtless stripped off the 
fragments, as can be seen in compound fractures, and as tliey are 
structurally continuous with the overlying soft parts they probably 
come quite accurately into place when the displacement is corrected, 
and thus form a fairly complete tubular sheath connecting the ends 
of the fragments and all splinters except those which are entirely 
loose, guiding and limiting the formation of the new tissue that is to 
establish the ultimate union. When this sheath is not complete, 
because of persisting displacement, the existence of the periosteal 
bridge is of extreme importance, because it maintains the connection 
between the fragments by means of a tissue whose activity in the pro- 
duction of bone is marked. The position and form of the callus in 
specimens of union with displacement indicate clearly the position and 
agency of the bridge, and Plate III. shows the ossification on the 
inner surface of the bridge, but not complete throughout the interval 
between it and the surface of the bone. 

At the same time blood is poured out from the torn vessels of the 
bone into the gap between the fragments and from the vessels of the 
soft parts into the interstices among the muscles. This blood is grad- 
ually absorbed during the first few days following the receipt of the 
injury, and at the same time the effects of the traumatism are mani- 
fested in the inflammatory oedema of the limb and the infiltration of 
a thick viscid liquid into the soft tissues immediately adjoining the 
seat of the fracture, the beginning of the firm ovoid mass which can 
always be felt at this point. The periosteum becomes much thicker, 
softer, and more vascular ; a thin layer of gelatinous or viscid liquid 
is found between it and the bone for a distance of a few lines from 
the edge of the fracture or from the point to which the membrane has 
been stripped up, and at the more distant limit of this layer the sur- 
face of the bone promptly become roughened by the formation of 
patches of new bone. The portions of the periosteum which have 
been stripped off, those which form complete or incomplete bridges, 
and the lacerated tissues which form the wall of the cavity in which 
the ends of the bone lie, granulate and pour out an exudate to mingle 
with the remaining blood. 

The marrow T shares in this production of granulations, and the cells 
of the connective tissue external to the periosteum share for a greater 
or less distance in the irritation, and by their proliferation bind to- 
gether all the adjoining parts in one firm, compact mass. The com- 
pact layer of bone, the cylindrical shell of the shaft, feels the same 
influence and reacts in the same manner, but much more slowly in 
consequence of the scantiness of its cellular elements. Its outer and 
broken surfaces soon show pink points which enlarge and send out 
granulations to join those already produced by the periosteum and 
marrow, and thus there is formed between the separated fragments a 
bond of union which is actually continuous, almost from the beginning, 
with all their constituent parts. The size and character of this bond vary 



THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 



Fig. 25. 



with the degree of displacement ; if the fragments remain nearly 
in their original relations to each other, the bond is short and sym- 
metrical, the granulations springing from the marrow meet and unite 
in the centre of the gap, while the thickened periosteum passes 
from one fragment directly to the other, remaining adherent to them 
or separated only by a layer of effused blood. If lateral displace- 
ment occurs and persists, the bond passes obliquely from the outer 
surface of one fragment to that of the other, and is much more 
complete at some points of the periphery than at others. Thus, in 
Fig. 25, which represents the condition on the seventh day, the firmest 
union is by the cartilaginous band crossing the 
angle at b and formed apparently by the thick- 
ening of a periosteal bridge. On the opposite 
side of the lower fragment the beginning of 
an incomplete band of similar structure is seen. 

The formative action thus begun is rapidly 
carried on, and principally by the periosteum 
and marrow. When the fragments are kept 
end to end an ovoid mass of tissue, having the 
consistency of jelly and a pearly white appear- 
ance, and continuous above and below with the 
periosteum, envelops them, the so-called " pro- 
visional " or " ensheathing " callus. This mass 
is formed not solely by granulations springing 
from the under side of the periosteum, but also 
by the thickening of that membrane and of the 
connective tissue on the outer side, including 
that which surrounds the adjoining muscular 
bundles, and according to Cornil and Coudray, 1 
even the cells of the sarcolemma. Composed 
at first of embryonal elements, it soon becomes 
cartilaginous in the portions formed by the per- 
iosteum ; then lime salts are deposited at dif- 
ferent points within it, and finally it is transformed into bone. 

The granulations that spring from the marrow ossify without passing 
through the cartilaginous stage, and the process here apparently begins 
at the fine lamellae which lie upon the inner side of the compact shell. 
The new lamellae extend across the canal, soon occluding it entirely, 
and also out into the interval to meet those coming from the other 
fragment. Thus is formed the internal or medullary plug. 

The granulations occupying the annular interval between the cortical 
layers of the two fragments (when the reduction is complete) apparently 
come mainly from the periosteum and pass through a cartilaginous 
stage before becoming bone, as do the others that have the same origin. 
They unite promptly with those of the medullary ping and ultimately 
(sometimes after a long delay) with the cortical layer. It was to this 
part of the callus that Dupuytren gave the name of " definitive callus." 
The cause of the delay in union with the cortical layer lies in the slow- 
ness with which the latter forms the granulations necessary to unite 
with the others, and doubtless to the occasional long persistence o\' a 
1 Cornil and Coudray. Revue de Chir., 24th year, No, 7. 




Tibia of rabbit. Seventh 
day : a, blood ; b, cartilag- 
inous callus ; c, muscles. 

(GURLT.) 



60 FRACTURES. 

necrotic scale of bone on its broken surface, which has to be slowly 
penetrated and absorbed by the granulations. The cellular elements 
of the cortex, which have to do the work of enlarging the Haversian 
canals and forming the granulations, are scanty, and those immediately 
adjoining the broken surface cannot share in the work because" their 
blood-supply is cut off by the clotting of the blood in the torn capil- 
laries. The cells situated a little more deeply have to carry on the 
work and slowly break through the intermediate necrotic scale before 
they can meet and unite with the other granulations that have spread 
into the interval from without and within. This process in the com- 
pact tissue is the usual rarefying osteitis, characterized by an enlarge- 
ment of the Haversian canals and a corresponding loss of the bone 
tissue, a change, in short, which transforms the cortex for a certain 
distance into spongy tissue like that of the ossifying callus. Ulti- 
mately the rarefaction ceases and a " productive" or "condensing" 
osteitis follows, by which the lamella? are thickened and the interme- 
diate spaces and canals contracted until the former proportions between 
them are measurably restored. Occasionally the ossification spreads 
into ligaments and tendons attached to the bone close by the fracture. 

While the callus is thus forming and ossifying, the irritation in the 
adjoining soft parts subsides, and they regain their original condition 
and functions more or less completely. Occasionally the associated 
injuries of muscles or tendons or the sheaths of the latter lead to per- 
manent disabling adhesions. 

After the ossification of the callus has been completed the excess on 
its exterior and even projecting portions of fragments slowly disap- 
pear, and in cases in which the reduction of the displacements has 
been exact this disappearance of the exterior callus may go so far as 
to leave little or no trace on the surface of its previous existence. In 
like manner the central plug diminishes and the medullary canal may 
be restored. 

Fragments of the cortical layer broken off at the time of the injury 
may remain attached to the periosteum, preserve their vitality, share 
in the same processes, and form a part, often an important one, of the 
callus. There is reason to believe also that even after they have been 
entirely detached they may form new connections with the soft parts 
and granulations, and preserve (or renew) their life. Such fragments 
have been found embedded so deeply in a callus that no other expla- 
nation than that of complete detachment can well be accepted. How- 
ship describes and figures one, and Gurlt another and remarkable one 
(Fig. 26). The possibility of this preservation has also been estab- 
lished by experiment upon animals. Portions of the shaft have been 
chiselled off, separated entirely from the soft parts, and replaced in 
contact with the bone ; examination after the lapse of some weeks 
showed re-establishment of vascular connection. 

It is also known that fragments may long remain without vascular 
connection embedded in a callus as well-tolerated foreign bodies. After 
the lapse of months, or even years, and from unknown causes, they 
may cause irritation ; an abscess forms, the bone softens about them, 
and either they are cast out spontaneously or they remain, provoking 
an interminable suppuration, until removed. 



THE REPAIR OE FRACTURES AND THE CLINICAL COURSE. 61 



Fig. 26. 



It occasionally happens that the callus does not ossify, and in some 
very exceptional cases the bone is entirely absorbed for a considerable 
distance on each side of the seat of fracture. The causes are not fully 
understood. The difference in the process consists in an entire or 
partial absence of productive osteitis and in an 
excess of the rarefying osteitis. The latter, I 
am convinced, is favored by the presence of a 
metallic suture in the bone. 

When the fracture is compound, and remains 
so, the details of the reparative process are dif- 
ferent to this extent: that the callus does not 
pass through the preliminary cartilaginous stage 
at any point where suppuration has occurred. 
The formation of the medullary plug is not 
affected, the granulations there being transformed 
directly into bone as they are in simple fractures; 
the difference is in the external or ensheathing 
callus. The reason of this difference, as shown 
by experiment, 1 lies in the destruction of the 
periosteum by the suppurative process, in the 
destruction, that is, of the only tissue whose 
granulations pass through the cartilaginous stage 
in forming the callus. 

The process is slower than after a simple frac- 
ture because the suppuration of the wound delays 
or prevents the formation of much of the exter- 
nal callus and throws most of the labor upon the 
bone itself, which, as has been shown, is the least 
able to do it. It is easy to watch the process. 
The ends of the bone are seen lying bare and 

,..., , n • i i Fracture of the neck of 

white in the wound; a mass of pink granulations the femur and of the shaft. 
forms at the limit of the denudation and ad- Aspiinter 5 inches long and 
vances slowly across the bared surface ; the nearly 1 inch wide > com ' 

bi n> ' n ,. . . ,i posed of the cortical layer, 

roken surface remains for a time quiescent, then has been turned completely 

granulations spring from it, beginning at the about its long axis and be- 

points nearest the medullary canal and spreading come united, with its orig- 

slowly toward the outer edge ; the wound gradu- ^1^^° 

ally fills up with these granulations, the bone is ments. (Figured by Gurlt 

covered in, and cicatrization follows. from the Museum of the 

In less fortunate cases a portion of the bared 2 03 ? 1 CoUege of Surgeons, 

i t t • on i r i n - r- England, No. 454.) 

bone dies and is cast oft by the formation of a 

line of demarcation which can sometimes be seen at the edge of the 
granulations, but which more commonly is hidden by them. It must 
not be thought that all the bare white bone seen in such a wound is 
dead, even after it has remained unchanged in appearance for several 
weeks. Its surface may, indeed, be dead, but the interior is often 
alive and able to cast off the dead superficial scale without aid. The 
granulations which form between the living and the dead parts seem 
1 Eigal and Vignal : Comptes-Kendus do 1' Academic des Sciences, L880, vol. xc. \\ 1218. 




62 FRACTURES. 

sometimes to dissolve and absorb the latter if they are small and thin, 
or, if not, slowly to bear them to the surface and cast them out. 

The callus thus formed is larger and more irregular than after 
simple fracture ; it remains tender and sensitive for a long time, and 
is covered by an adherent scar at the seat of the wound. Fragments 
formed at the time of the accident and remaining attached to the peri- 
osteum usually preserve their vitality ; if not, they become detached 
after a time and are found loose in the wound, or become shut in by 
the callus and prolong the suppuration indefinitely. In this latter case 
the constant irritation due to the presence of the foreign body, the exist- 
ence of sinuses, and the burrowing of the pus interfere with the evolu- 
tion of the callus. Instead of undergoing a gradual and uniform 
diminution and condensation, it becomes eburnated at some points and 
entirely absorbed at others, irregular prominences appear on its surface 
or follow the lines of attached tendons and fascia?, and its interior is 
occupied by cavities of various sizes usually suppurating and in com- 
munication with the exterior. 

In the spongy bones and the spongy ends of the long bones less of 
the work of repair is done by the periosteum and more by the bone 
itself, for the periosteum is so interrupted by attached tendons and 
ligaments that it is less freely stripped up, and the bone surfaces are 
broadly in contact and, being spongy, are ready at once to form gran- 
ulations without preliminary rarefaction. 

In fractures involving joint-surfaces the absence of periosteum and 
other soft tissues on the articular surface prevents the formation of an 
external callus on that side, and union takes place by granulations 
arising directly from the fractured surfaces and by an external callus 
at the extra-articular parts of the fracture. The line of the fracture 
on the articular surface is marked by the absence of cartilage over it, 
and usually by a groove. The fracture of the cartilage does not heal 
by the formation of new cartilage ; usually the callus is covered at this 
point by a firm white layer of fibrous tissue, but sometimes the bone 
is bare. In exceptional cases the callus is exuberant and grows out 
beyond the level of the cartilage, forming an irregular mass in place 
of the usual groove. 

Fracture of cartilage (costal cartilage, larynx, etc.) is repaired partly 
by a fibrous, rarely a cartilaginous, band between the fragments, and 
partly by a bony peripheral callus. (See Chapter XVI.) 

Exuberance of the callus, both external and intermediate, is a fre- 
quent cause of diminution of the functions of the joint by destroying 
the normal relations of the articular surfaces, by filling up normal 
depressions, and by creating abnormal prominences. These results are 
usually beyond the control of the surgeon, and the latter are most 
common in the young, whose power of producing bone is greatest. 
Occasionally the productive process excited by the fracture extends far 
beyond the limits of the latter, and not only may the joint itself be 
obliterated by fusion of the bones which constitute it, but the process 
may also spread to and produce the same result in neighboring joints 
as in the case represented in Fig. 27. 

Bones which lie parallel and close to each other, as those of the fore- 



THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 63 

arm and leg and the ribs, may become united by an exuberant callus 
when either one or both are broken. This consolidation is most likely 
to occur when both bones are broken at the same level, and when dis- 
placement of one or more of the fragments diminishes the normal inter- 
val between them. The mass of granulations developed about one 
fracture becomes continuous with that developed about the other, and 
ossification follows. The presence of an interosseous membrane favors 
this result, for this tissue has the same tendency to ossify that is shown 



Fig. 21 




Fig. 2£ 





Bony anchylosis of the foot and ankle 
after fracture of the leg. (Gurlt.) 



Absorption of the neck of the femur after fracture. 



by other white fibrous tissue in the presence of a productive osteitis. The 
effect of this consolidation is, of course, to prevent independent motion 
of the two bones, and while of no importance in the leg and of little, if 
any, in the ribs, it produces a very serious disability in the forearm by 
abolishing pronation and supination. It occasionally happens, when two 
bones are broken at the same level, that the calluses grow into contact 
with each other but do not unite. Their adjoining surfaces are smooth 
and together form a sort of lateral joint which may allow movement 
of one upon the other. 

When the line of fracture follows that of a still existing epiphyseal 
cartilage, either wholly or in part, and the fragments arc not displaced. 
union apparently takes place as readily as after simple fracture, but 
nothing poskive is known of the details oi' the process. The injury 
does not necessarily interfere with the subsequent growth of the bone : 
the layer of cartilage may remain unossitied and perform its functions 



64 FRACTURES. 

as before ; but it is known from the results of experiments upon ani- 
mals, and from cases of inflammatory disease and from some of trau- 
matic separation without displacement, that the effect of irritation of 
the epiphyseal cartilage is sometimes to hasten its ossification, and thus 
arrest the growth of the limb. This last result must certainly be pro- 
duced when the epiphysis is dislocated by the fracture and is not 
restored to its place. 

Finally, failure of union after fracture may be due to arrest of the 
reparative process in the granulation stage, ossification not taking 
place and the bond between the fragments remaining fibrous, or to the 
wide separation of the fragments, or to the interposition of a bundle 
of muscular tissue, or to the insufficiency of the blood-supply of one 
of the fragments. This condition, especially as seen after fracture of 

Fig. 29. 




Fracture of the olecranon : fibrous union. (Malgaigne.) 

the shaft of a long bone, is considered in detail in Chapter VIII., 
Pseudarthrosis. Examples at other points than the shaft are furnished 
especially by the patella and olecranon (direct longitudinal separation), 
and by some fractures of the neck of the femur where the cause lies 
in an excess of the rarefying process, by which the neck is destroyed, 
or in the cutting off of the blood-supply by complete rupture of the 
periosteum of the neck which carries vessels to the head. 

Clinical Course. 

This varies with the position and character of the fracture and espe- 
cially with the complications arising from the peculiarties of the 
fracture and the health and age of the patient. Ordinarily, in simple 
cases, after the primary reaction of the injury has subsided and an 
appropriate treatment has been established, the patient goes on to 
recovery without pain, fever, or other disturbance of his general 
health, and incommoded only by the disability of the limb and the 
confinement to which he is subjected. But in the alcoholic this tran- 
quil course may be promptly interrupted by the onset of a pneumonia 
or an attack of delirium tremens; and in the old, confined to bed by a 
broken thigh or leg, the primary shock may be sufficient to cause 
death in the first few days, or the general health may begin to suffer 
about the third week, and death follow after a short interval marked 
by symptoms of hypostatic pneumonia or mild delirium and gradual 
failing of the strength. And very, very rarely, even in simple cases 



THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 65 

and without the slightest warning, death may come suddenly in the first 
few days by fat embolism of the lungs, or at a later period by a car- 
diac pulmonary embolus detached from a thrombus in some large vein. 

For the first day or two the patient may suffer pain at and near the 
fracture, augmented by muscular twitchings, and considerable discom- 
fort from the weight and tension of the swollen limb ; and if the bone 
is a large one (thigh, leg, arm) and the fright and emotion at the time 
of the accident extreme, the symptoms of shock may be well marked. 

The temperature usually shows a rise of from one to two degrees 
Fahrenheit, " aseptic" fever, which promptly diminishes, and disap- 
pears within a few days. At the same time the urine may contain a 
small amount of albumin and free fat and hyaline casts enclosing 
brown granules. The fat, which is sometimes sufficient to form a dis- 
tinct layer on the surface after standing, is thought to come from the 
crushed marrow of the bone, and the variations in its quality and the 
time of appearance to depend upon its temporary arrest in the pulmo- 
nary capillaries (fat embolism, q. v.). The brown casts are sometimes 
very numerous, but more often are wholly lacking. 

Bernadi 1 has shown that a leucoeytosis, more marked in the young 
than in adults, appears in a day or two and reaches its maximum in 
ten or fifteen days. The eosinophils first diminish, then increase 
rapidly in cases that do well ; their increasing diminution is an unfavor- 
able sign and suggests grave complications. 

The limb swells, partly because of extravasated blood and shorten- 
ing, but mainly by oedema; the swelling reaches its maximum on the 
second or third day and then slowly subsides. The skin of the involved 
region shows a yellowish tinge, the result of staining with the coloring 
matter of the extravasated blood, and ecchymoses appear at points 
below and sometimes above the fracture. Larger or smaller blebs 
appear, especially on the legs, by the second or third day, and may 
interfere with the early application of a fixed dressing. 

As the swelling subsides a firm ovoid mass becomes recognizable, 
extending above and below the fracture, and the sensitiveness on 
pressure diminishes; this mass diminishes in size and increases in firm- 
ness as time passes, the abnormal mobility diminishes, and finallv, 
after a length of time which varies greatly in different cases, ceases, 
and union is then effected, although not so firm as it will ultimately 
become after ossification shall have been completed. A small, hard 
mass can still be felt at the seat of fracture which will slowly diminish 
for months, perhaps for years. 

Other things being equal, and bone for bone, less time is required 
to complete repair in children than in adults ; and fractures heal as 
rapidly in one sex as in the other, and in the old as rapidly as in the 
middle-aged. As a general rule, too, the larger the bone the longer 
the time required, and fractures of the shaft require more time than 
those of the spongy ends, and those with uncorrected displacement 
more than those in which the normal relations have been maintained 
or restored. The average for fractures of the shaft of the long bones 

'Bernadi: Alcime modificazioni nel sangue del f'ratturati. Pisa, 1907. Abst in 
Zentralblatt fur Chir. 1908, p. 1421. 
5 



6(3 FRACTURES. 

in adults varies from four weeks for the clavicle or forearm to eight or 
nine weeks for the thigh. 

But with the union of the fracture the recovery of the patient, espe- 
cially after fractures of the limbs, is not yet complete. The circula- 
tion of the part, the skin, the muscles, and the neighboring joints have 
yet to recover from the disabilities imposed upon them by the primary 
injury or by the prolonged disuse of the limb. The skin is harsh and 
dry; the limb swells and shows venous congestion when used, and 
especially when dependent, presumably because of plugging of the 
veins and possibly because of rupture of lymphatic channels ; the 
joints are swollen, stiff, and sensitive. As a rule, all these features 
disappear under use, and more rapidly in the young than in the old, 
but occasionally some of them persist for a long time. 

The course of the case, as thus sketched, may be greatly modified by 
exceptional severity of the injury, by associated lesions, or by a wound 
or contusion which makes the fracture compound either immediately 
or after the lapse of a few T days. In the severe cases, with more splin- 
tering of the bone and laceration of the soft parts, the pain, swelling, 
and general and local reaction are greater and more prolonged, but 
very rarely end in suppuration. 

The direct implication of a joint in a fracture, or the spread to it of 
the neighboring reaction, or the presence of a concomitant sprain, as 
is so often seen at the knee in fractures of the thigh, adds an arthritis 
which increases the pain and discomfort, and may delay recovery or 
diminish its completeness. 

In compound fractures with a small, clean wound it has seemed to me 
that the local and general reaction is even less than in simple fracture, 
presumably because the extravasated blood escapes through the wound, 
with consequently less tension and less absorption of fibrin-ferments to 
cause fever. Under appropriate treatment such a wound heals in a 
few days, and the course is thenceforth that of a simple fracture. 

In compound fractures with bruising of the skin that prevents pri- 
mary union of the wound, and in those made compound by the slough- 
ing of the bruised skin, the course may be very different. It is that 
of a deep, lacerated wound, from whose walls sloughs must be cast off, 
and in which suppuration is inevitable and serious infection possible. 
In the milder forms the suppuration is slight and limited to the super- 
ficial portions of the Avound, and the course is practically that of a 
simple fracture with only the delay due to tardier union of the bone 
and cicatrization of the wound. But in the severer forms all the local 
and general symptoms are more marked, the swelling is greater, the 
fever higher and persistent. If treatment fails to overcome the infec- 
tion the pus burrows amid the muscles, neighboring abscesses form, 
with chills and exacerbation of the fever, and amputation may be indi- 
cated to save the imperiled life. Or, by counter-openings, drainage, 
and the free use of antiseptics, the suppuration may be brought under 
control, and then the patient pursues his weary course toward conva- 
lescence through the pains and perils of the slow casting off of necrotic 
fragments of the bone and the tardy formation and ossification of the 
granulations that must take their place. Such cases are often despair- 



THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 07 

ingly slow in reaching solid union and closure of the sinuses, and still 
longer in regaining use of the limb. The callus is large, the cicatrix 
adherent and sensitive, the adjoining muscles hampered by adhesions. 
The condensation of the callus is liable to become extreme in portions, 
because of the prolongation of the irritation, and thereby to cause par- 
tial necroses which prolong or renew the suppuration in the efforts to 
cast them out, so that the sinuses may persist intermittently for years 
with longer or shorter interruptions. 



CHAPTER VI. 

COMPLICATIONS AND REMOTE CONSEQUENCES. 

Early Local Complications : Skin, bloodvessels, gangrene, degeneration of mus- 
cles, suppuration. Early General Complications : Septicaemia, fat embolism, 
delirium tremens, tetanus, pneumonia. Late Local Complications : Excess- 
ive painful callus, tumor, injury of nerve, weak callus, arrest or exaggeration 
of growth, stiffness of joints, atrophy, thrombosis, and embolism. 

These may be local or general, and the complications may be the 
direct and immediate result of the primary violence or the later result 
of the primary lesions, of infection, or of constitutional conditions. 
Some are peculiar to fractures, others may arise also in connection with 
other forms of injury. 

Early Local Complications. 

Skin. The sharp point of the upper main fragment may be forced 
through the overlying muscles and fascia and perforate the skin or 
become engaged in its deeper layers in such a way that its reduction is 
difficult, or it may make such pressure upon the unbroken skin that 
the latter will slough at the point of pressure in the course of a feAV 
days. The first condition may sometimes be corrected by traction upon 
the lower segment of the limb, but usually an incision will be neces- 
sary to effect a complete reduction of the displacement. If perforation 
has taken place the opening should be at once enlarged, for this does 
not add to the chance of infection, and greatly simplifies reduction. 

Pressure upon the unbroken skin must be relieved by reduction, or 
at least by diminution of the displacement ; and if this is not possible 
the bone should be exposed by incision and the projecting portion cut 
away, for such a wound can be so protected that it will heal promptly, 
while one made by sloughing will surely suppurate, and even if danger- 
ous infection thereby of the seat of fracture is avoided, yet the wound 
will be slow to heal, and will leave an adherent and possibly sensitive 
scar. 

The sloughing of the skin contused by the primary violence is rare 
except in connection with compound fracture — that is, violence which 
is sufficient to kill the skin generally breaks it. Theoretically, it 
would be well immediately to remove all skin and other tissues that 
have been thus killed, in order more surely to avoid infection ; but the 
limits of such destruction cannot be determined with sufficient accu- 
racy. A fairly accurate estimate of the probability of sloughing and 
its extent can be made by applying a rubber bandage tightly to the 
limb for a few minutes, as in producing artificial ischaemia for opera- 



COMPLICATIONS AND REMOTE CONSEQUENCES. 69 

tion, and noting the areas which do not share in the blush following 
its removal. This test is fairly accurate except for areas of skin on the 
distal side of long transverse wounds ; such generally remain pale, even 
if viable. The failure of blood to flow on minute puncture of the skin 
is also a fairly accurate indication of its death. 

Bloodvessels. Rupture or serious bruising of the main vessels of a 
limb is a serious but infrequent complication. Among the more impor- 
tant vessels that have been thus injured in simple fracture are the mid- 
dle meningeal and carotid arteries in fractures of the skull, the sub- 
clavian vein and artery, and the acromial branch of the acromio-thoracic 
artery in fractures of the clavicle, the brachial and axillary artery in 
fractures of the humerus, the popliteal artery and vein in those of the 
lower end of the femur, and the anterior tibial in those of the leg. 
In compound fractures the same vessels and also those lying at a 
greater distance from the bone may be injured. 

The rupture of an artery in a simple fracture may lead to fatal 
hemorrhage, even if the vessel is a small one, in case the blood can 
escape into a large natural cavity, as in a unique case of fatal hemor- 
rhage following rupture of a small branch of an intercostal artery after 
fracture of a rib ; l but in a limb it leads either to the formation of a 
traumatic aneurism or to gangrene. The rupture may be immediate 
or it may occur after a few days by sloughing of the bruised vessel. 

The symptoms are a rapidly increasing local swelling, which pulsates 
after it has ceased to increase, and (in. the case of the main artery) 
absence of the pulse in its distal branches. Gangrene is more directly 
due to interference with the venous flow by the pressure of the swelling 
than to loss of arterial supply, and consequently appears in the " moist" 
form, characterized by swelling, duskiness, and coolness of the limb. 

The object of early treatment is to check the hemorrhage and favor 
the venous flow by elevation of the limb, possibly combined with 
digital pressure upon the main trunk or with snug bandaging from the 
lower end of the limb to a point well above the injury. If a well- 
defined aneurism forms it may be treated, after union of the fracture 
has taken place or is well advanced, by proximal or local ligature of 
the artery. Possibly, if gangrene threatened, the limb might be saved 
by a free incision through which the escaped blood could be turned 
out, thus relieving the pressure on the veins, and by tying the artery. 

In compound fractures the diagnosis is made by the profuseness and 
arterial character of the bleeding ; and the treatment is to tie the artery 
at the point of injury. But it not infrequently happens that after 
complete rupture of arteries as large even as the femoral the hemor- 
rhage promptly ceases spontaneously. Bleeding from a torn vein is 
more persistent and often profuse. 

Rupture of a large vein cannot be certainly recognized in a simple 
fracture, and its treatment is controlled by that of the gangrene which 
it may cause. In compound fractures the vessels may sometimes he 
seen and tied, but probably the associated lesions will be such that 
amputation will be indicated. 

Thrombosis of an artery, and doubtless also of a vein, maybe caused 

1 London Medical Times and Gazette, I860, ii.. p. (507. 



70 FRACTURES. 

by the direct violence which causes a fracture. I have seen examples 
in the arteries of the arm and leg broken by the passage of a wheel, 
the condition being found on examination of the limb after amputation 
because of gangrene, and others have been reported. Thrombosis of 
a vein may be caused by the pressure of a displaced fragment. A 
case involving the femoral vein and ending in gangrene and amputa- 
tion is reported in the Deutsche med. Wochenschrift, June 8, 1892, p. 
549. 

Gangrene may be local or general : the former the result of crushing 
of the skin and other soft parts in direct fracture, the latter the result 
of injury to or compression of the vessels or of tight bandaging. 

Local gangrene is manifested by the darkening and hardening of an 
area of skin surrounded by an inflammatory zone ; the swelling and 
fever are more marked and persistent, and when the dry patch is split 
or cut away an abundant thin, pink or dark, and offensive exudate 
escapes from beneath it and from the adjoining subcutaneous and inter- 
muscular planes. The infection must be combatted by free removal of 
the dead and dying tissues, irrigation, and drainage. The danger of 
general infection is great, and amputation is often required to save life. 

Gangrene of the limbs is usually of the moist form and begins with 
coolness and discoloration of the toes or fingers, the latter beginning 
as a deep-red color, and soon changing to purple and grayish-black. 
Dark blebs may appear on the surface, or the epidermis may be exten- 
sively but slightly raised by a thin, dark serum. If taken in time, 
and if the cause can be removed, as in tight bandaging, the life of the 
part may be preserved, and I have thought that keeping the limb in 
hot water (100° to 102° F.) was helpful ; but the vitality of the skin 
is greater than that of the muscles, so that even if the circulation 
returns in the former the muscles may yet disintegrate and the limb 
be lost. I saw this result in a case of fracture of the olecranon which 
had been treated by the immediate application of a pi aster- of- Paris 
dressing. The patient entered the hospital on the fifth day, with the 
uncovered hand black and swollen ; the dressing was removed, and the 
limb placed in a hot bath. Two days later circulation was re-estab- 
lished in the skin of the hand and forearm, but a week later incisions 
had to be made in the forearm, through which the muscles appeared 
wholly disorganized and diffluent. 

It must be borne in mind that even a narrow circular constriction, 
as by a band of adhesive plaster, is sufficient to produce this disastrous 
result, and is, perhaps, even more likely to do so than an equally tight 
bandage covering the limb. Consequently the longitudinal strips of 
plaster used in making traction should not be reinforced by the circular 
strips which are sometimes applied with the idea of keeping the former 
more securely in place. 

Degeneration and contraction of the muscles, the result of arrested 
blood-supply by bandaging or injury to the arteries, is occasionally seen ; 
it is a lower grade of the change mentioned in the preceding section. 
Volkmann, who first described it, gave it the name of " ischemic con- 
traction." It is most frequently seen in the forearm after fracture of 
the radius and ulna or supracondylar fracture of the humerus and is 



COMPLICATIONS AND REMOTE CONSEQUENCES. 71 

marked by atrophy and shortening of the muscles, the fingers being 
permanently flexed. This change is brought about by rapid degenera- 
tion of the muscular fibres and subsequent reactive increase and con- 
traction of the connective tissue. It is to be distinguished from similar 
contractures due to nerve injury or disease by its prompt appearance. 
In the less severe cases something may be gained by massage, electricity, 
and persistent efforts to straighten the fingers. Hildebrand, 1 who had 
noticed signs of involvement of the nerves, obtained partial relief in 
3 cases by removing the nerve trunks from among the shrunken mus- 
cles and lodging them between the fascia and the skin. Kleinschmidt 
and Hoffa 2 got good results by excising about an inch of the radius 
and ulna, thus giving the flexor muscles adequate length. 

Suppuration in simple fractures is very rare, and when it occurs it 
appears to be due to auto-infection, by germs carried by the blood and 
possibly brought from some suppurating focus in a distant portion of 
the body, as a furuncle ; rough handling of the broken limb and 
neglect of proper care apparently favor its occurrence. It promptly 
makes the fracture compound by spontaneous or surgical opening, and 
the course and prognosis are then those of an open infected fracture. 

Suppuration in compound fractures can generally be prevented or 
restricted to the superficial layers when the wound is small and its 
edges not contused, as is ordinarily the case in fractures by indirect 
violence. The later its appearance, the less likely is it to spread widely 
among the muscles and endanger life. 

In compound fracture with bruising and extensive laceration, sup- 
puration may remain as a local complication, the pus escaping freely 
to the exterior and the infection not spreading; the graver cases will 
be considered in the following section. 

Early General Complications. 

Septicaemia. This grave complication occurs in compound fractures 
and in simple ones followed by gangrene of the limb or suppuration at 
the seat of fracture. The most prompt, rapid, and fatal forms are 
seen in compound fractures accompanied by much bruising and lacera- 
tion of the soft parts and in those patients whose vitality has been 
lowered by alcoholism, disease, or age. 

A dusky-brown tinge discolors the skin about the wound and spreads 
rapidly upward, especially on the sides and back of the limb ; the torn 
muscles become gray and less moist, an offensive odor appears and 
grows rapidly more marked, and a thin offensive discharge escapes at 
the surface of the wound and can be pressed out from its recesses. 
The limb swells far above the fracture, the temperature rises, the 
patient becomes apathetic and slightly delirious. Occasionally pressure 
with the fingers upon the discolored skin provokes the slight crackle 
of emphysema, evidence of decomposition with production of gas, and. 
if well marked, strongly suggestive of the presence of one of the most 
rapidly fatal infections known, that of the " vibrion septique " of 
Pasteur, or the bacillus capsulatus aerogenes (Welch), the germ of 
acute gangrenous septicaemia. 

Amputation alone, with vigorous disinfection of the stump ami of 

1 Hildebrand : Saninilung klin. Vortrage, 1906. Chir. No. 122, 
'Kleinschmidt and Hoffa : Zentralblatt fur Clur., 1907, p, 81, 



72 FRACTURES. 

the subcutaneous tissue throughout the discolored area, can save life, 
and that only in so small a proportion of the cases that no one can be 
blamed for declining to resort to it. The peroxide of hydrogen appears 
to be a valuable antiseptic in these cases ; it can be forced under the 
skin with a syringe or through incisions which will serve also for 
drainage. The germ is anaerobic. I have known only two in which 
the septic vibrio was present to recover ; in a few cases in which the 
early symptoms indicated its presence I have changed the diagnosis 
because the patient did not fail so rapidly as I anticipated, and in every 
such case culture tests have shown its absence. Air which occasionally 
makes its way through the wound into the adjoining cellular tissue 
must not be mistaken for the gas of this decomposition. 

In the less acute cases septic infection follows the establishment of 
suppuration and is less marked locally and generally. The limb swells 
and becomes discolored, but the color is a dusky red and its area is 
limited ; the swelling is more like the common inflammatory bogginess, 
and incisions into it give exit to pus or inflammatory serum which has 
not the odor of decomposition. Such processes may be arrested by 
free incisions, drainage, and antiseptics ; but complete recovery is long 
delayed by necrosis of the ends of the fragments. 

Fat Embolism. As has been stated in Chapter III., free fat can fre- 
quently be found in the urine during the first two or three days after 
fracture. It is reasonable to suppose that it comes from the lacerated 
marrow, entering the circulation either directly through the torn and 
gaping veins of the bone or through the lymphatics. When thus 
taken up in considerable quantities it may be arrested in the pul- 
monary capillaries or, after having passed through those, in the capil- 
laries of the systemic circulation, and occasion serious symptoms or 
even death. Although the subject has been studied by several, by 
observation and experiment, since Von Recklinghausen first noted it 
in 1884 as a cause of death by plugging the pulmonary capillaries, its 
symptomatology is not at all clear, presumably because it is masked 
by the functional disturbances created by its interference with the 
circulation in various organs, notably the brain. There is even reason 
to think that it has something, perhaps much, to do in some cases 
with the phenomena classed as shock, with delirium tremens, which is 
so much more common after fractures than after other injuries, and 
with the pulmonary oedema and early pneumonias of the alcoholic 
and aged. 

The pathological conditions revealed on autopsy are oedema of the 
lungs and extensive plugging of the pulmonary capillaries, and 
sometimes even of the arterioles, with free fat, similar but less ex- 
tensive plugging of the systemic capillaries, often marked by small 
hemorrhages, and sometimes extensive filling of the renal glomeruli. 
The local reaction is that of the beginning of infarction, and probably 
in the cases which survive it is arrested by the prompt forcing of the 
fat through the capillaries and the re-establishment of the circulation. 
Since the emboli are not septic the element of infection does not enter 
into the case, and death is due to the mechanical interference with 
the nutrition and functions of the parts involved. 



COMPLICATIONS AND UEMOTE CONSEQUENCES. 73 

The symptoms in well-defined cases confirmed by autopsy have 
begun within twenty-four hours after the injury, rarely after two or 
three days, and usually with quickening of the respiration that some- 
times become marked dyspnoea; undiminished resonance of the chest 
and abundant, coarse rales ; little or no fever ; face at first pale, then 
cyanotic ; unconsciousness followed, and death within a few hours. 
In other cases the central nervous symptoms have been the most 
prominent : unconsciousness, noisy and slow breathing, muscular 
twitching, and even convulsions, and sometimes paralyses. Most 
tragical are those cases, fortunately very rare, in which the complica- 
tion proves rapidly fatal in a young and healthy patient after a simple, 
comparatively unimportant fracture, such as a Pott's at the ankle, 
with which the idea of danger to life is not associated. 

Treatment is apparently almost powerless to help ; the indications 
are to prevent further crushing of the marrow by immobilization of 
the limb, to stimulate the heart, and to aid the respiration by inhala- 
tions of oxygen when dyspnoea is present. 

Delirium tremens is a not infrequent complication of fracture in hos- 
pital cases. The course is less severe and the prognosis better than 
in cases not excited by traumatism. Its occurrence appears to be 
favored not only by the traumatism, but also by the withdrawal of 
the customary stimulant which usually follows admission to a hospital, 
and I have found it advisable, therefore, as routine practice to give 
alcohol in moderate quantities during the first week to those injured 
who are habitual, even if not excessive, drinkers. The attack begins 
with restlessness and sleeplessness, and when fully developed presents 
the usual symptoms. In addition to alcohol, sedatives are indicated, 
together with cathartics and a light, nutritious diet. Usually the attack 
subsides after one good night's rest has been obtained. 

Tetanus is a rare complication, almost unknown in simple fractures 
and much more frequent in compound fractures of the hand and 
fingers than in those of other bones. Excluding those of the hand 
and fingers, I have seen it only in one fracture of the femur (gunshot) 
and in two of the forearm (compound). Although the microbic nature 
of the disease has been established, it is noteworthy that many of the 
attacks are preceded by a sudden fall in the temperature of the air. 
One of my cases developed after such a fall, and on the same day two 
cases occurred in two other hospitals in the city. 

Pneumonia, developing on the second or third day, is a rather fre- 
quent and dangerous complication. Reference has been made to its 
possible origin in fat embolism of the lungs. It begins more fre- 
quently without a chill than with one, and, in our hospital cases at 
least, is likely to run a rapid, severe course, with high fever and 
delirium, often terminating fatally in three or four days. 

Pneumonia appears also as a late complication in the old and feeble. 
beginning insidiously, and pursuing an asthenic course, with moderate 
fever and mild delirium, and ending usually in unconsciousness and 
death. Prolonged recumbency is thought to favor its occurrence by 
promoting venous congestion of the lungs, but it appears to me to be 
rather a relatively unimportant incident in a general failing ol' the 



74 



FRACTURES. 



strength which is usually manifest a few days before the signs of con- 
solidation appear, and to which the death appears to be due quite as 
much as to the pneumonia. I have learned to look for this change 
especially in fractures of the neck of the femur in the old and feeble. 

Late Local Complications. 

The callus may be excessive, painful, or weak, or may become the 
seat of a sarcoma. A callus may be unusually large, " exuberant," 
either because the fragments remain widely displaced during repair, 
or because ossification extends far beyond the usual limits, or because 
the presence of a necrotic fragment maintains irritation and delays the 
termination of the productive process. The first variety is not prop- 
erly to be termed a complication, for the size of the callus is necessary 
to firm union. The second is seen especially in the neighborhood of 
joints, as the result of the persistent displacement of a fragment, or of 
ossification of muscular attachments, ligaments, or capsule in the old, 
or of exaggerated productive actiyity of the periosteum in the young. 
The third is rather common after compound fractures that have sup- 
purated. 



Fig. 30. 



Fig. 31. 





Intra-articular fracture of the lower end Exuberant callus ; fracture of lower end 

of the humerus, with exuberant callus, of humerus, 

especially in front. 

Enlargement near a joint may mechanically restrict its range of 
motion, and at other points it may, in like manner, interfere with the 
action of a muscle or make disabling pressure upon a nerve or inter- 
fere with the venous circulation in the limb. 

An exuberant callus may, and usually does, diminish in size, but 
not sufficiently to remove marked obstacles to function. Such removal 
can be effected only by surgical measures, the cutting away of the 
exuberant mass ; local applications made to the surface with the object 



COMPLICATIONS AND REMOTE CONSEQUENCES. 75 

of promoting its aosorption are useless. The same pressure -effects 
can be produced by persistent displacement of the fragments, and it 
is not always possible to determine, previous to operation, whether 
the offending mass is a fragment or the callus. 

Painfulness of the callus may begin early in the course of repair 
and persist long after union has become complete, or it may begin 
after an interval, sometimes a very long one. Many patients com- 
plain of dull pain in the limb for months, even for years, after the 
injury, especially after prolonged use and in connection with changes 
in the weather, but the cases in which the pain is limited to the callus 
are rare. The late form, that in which the pain begins after an in- 
terval, is clearly inflammatory, the inflammation being generally a 
recurrence in an old suppurative focus, manifesting itself by fever, 
swelling, and tenderness, and relieved by spontaneous or surgical 
evacuation of the pus. 

The early continuous form is not inflammatory, but the causes are 
not always clear. The pain has been attributed to pressure upon a 
nerve either without or within the callus, to a neuritis set up by in- 
jury of a nerve at the time of the accident, as is seen also after wounds 
involving only the soft parts, and to a supposed persistent osteitis or 
an osteo-neuralgia (Gosselin) the cause of which is equally conjectural. 
The pain may be continuous or intermittent, and exacerbated at night 
or by change in the weather. It must be distinguished from pain due 
to injury of, or pressure upon, a nerve. 

Counter-irritation on the surface has given relief, and I should think 
that in the rebellious cases it might be advisable to incise the perios- 
teum or to cut into or chisel away the bone. 

The development of a tumor, sarcoma, at the site of a healed frac- 
ture, within a few weeks or after an interval of several years, has been 
occasionally observed, and apparently belongs in the same etiological 
group as that of sarcomata following other injuries of bone or soft 
tissues. Still rarer is the development of carcinoma after fracture in 
those who have or have had a carcinoma at another point. Pearce 
Gould (Lancet, April 25, 1896) refers to one such case, fracture of the 
humerus in a lady whose breast had been removed for carcinoma five 
years previously ; he explored very carefully by operation, without 
finding any sign of tumor; "two months later an extensive growth 
had appeared at the seat of fracture." 

Associated Injury of a Nerve. A nerve may be bruised or completely 
ruptured at the time of the accident, or it may become stretched over 
the edge of a fragment or by the growing callus, or compressed within 
a more or less complete canal formed about it by the callus or by cica- 
tricial tissue developed in the soft parts. Primary rupture of a motor 
nerve is liable to be overlooked at first, because of the withdrawal o'i 
the limb from use in consequence of the fracture, but it is not prob- 
able that the resultant delay diminishes the chance of successfully 
uniting the divided portions by operation, and on some accounts the 
operation is more free from risk if not undertaken until after the frac- 
ture has become united. The diagnosis of rupture cannot always be 
safely made on immediate paralysis of the muscles supplied by the 



76 



FRACTURES. 



nerve. I once operated upon a ease of supposed rupture of the 
musculo-spiral nerve in connection with fracture of the shaft of the 
humerus, and found the nerve untorn and apparently uninjured for 
some distance above and below the fracture. It must also not be 
hastily assumed that an operation to reunite the nerve has failed ; in 
two cases (musculo-spiral nerve) I have seen function return after 
nearly a year had elapsed since the operation. 

The compression of a nerve by a displaced fragment may abolish its 
functions or may excite a neuritis manifested by modifications of sensi- 
bility and sometimes by great pain ; similar effects may be produced 
by a coincident contusion of the nerve. The most frequent examples 
are in fractures above the elbow and above and below the knee ; occa- 
sionally it is seen in fractures of the clavicle, upper end of the humerus, 
and pelvis. 

Similar compression may be made by the callus upon a nerve which 
crosses or passes through it. Of late years a number of such cases 
have been operated upon, and various gross changes noted in the nerve, 
which is usually reduced in size for a greater or less distance below and 
shows a notable enlargement just above the point of pressure. 

The treatment consists in the removal of the corresponding portion 
of the bone or callus, and this should be done freely. I have thought 
it advisable in some cases to interpose a strip of periosteum or other 
soft tissue between the nerve and the cut surface of the bone in order 

Fig. 32. 




Inclusion and compression of the musculo-spiral nerve in a callus. A in 2 shows a bony bridge 
crossing the nerve, and in 1 shows the surface left by its removal. The dotted area shows the 
surface left after the cutting away of the sides of the bony gutter. 



to diminish the probability of the nerve becoming included in 
adherent and possibly compressing cicatrix. » 



firm 



COMPLICATIONS AND REMOTE CONSEQUENCES. 77 

Weakness of the callus, which should not be confounded with delay 
in consolidation, is manifested in two ways : by its yielding under use 
of the limb after union, as judged by the usual tests, has appeared to 
be complete, and by a later loss of its strength under the influence of 
intercurrent local or general causes; the latter is also termed softening 
or absorption of the callus, and in either case, if fracture occurs, it 
is termed secondary fracture. The weakness may be due to insuffi- 
ciency in the amount of the callus, as when a gap has been created 
between the principal fragments by their displacement or by loss of 
bone, or in the ossification of the bond uniting the fragments. In 
either case the bony bridge uniting the fragments is not strong enough 
to bear the strain of use, and it either breaks completely or yields 
enough to permit an angular displacement. 

Softening of the callus under the influence of a general disease — 
e. g., scurvy, typhoid fever, erysipelas — has been observed in a few 
cases, sometimes after the lapse of many months. Clarke, quoted in 
the Traite de Chirurgie, reported a case in which the softening ap- 
peared to be the result of overwork in school. The callus has been 
felt to diminish in size, and abnormal mobility to reappear without the 
intervention of any violence. 

Secondary, or u iterative," fracture without apparent defect or 
change in the callus is a not infrequent accident due to premature use 
of the limb or to slight external violence. Gosselin tells of a man 
twenty-five years old who broke his femur six times in twenty 
months ; the fractures occurred in the second week after he began to 
walk and in consequence of a slight effort, as in dancing, running, 
and trying to avoid a fall ; each time the patient had left his bed on 
the forty-fifth day. The symptoms are those of primary fracture, 
but usually less marked. 

Arrest of growth of the bone is occasionally observed in the young 
after fracture at or near the epiphyseal cartilage. (See Separation of 
the Epiphyses, Chapter II.) 

Exaggeration of growth of the bone after fracture has been observed 
in a very few cases, in consequence either of stimulation of the epi- 
physeal cartilage to greater activity or of exaggerated production of 
bone at the fracture. Cases have been reported in which a consider- 
able shortening noted immediately after recovery has disappeared in 
the course of a year or two. There is usually room in such cases ful- 
some doubt of the accuracy of the observation. Enlargement of the 
patella after close reunion by operation has been observed in a number 
of cases, both in breadth and length. 

Stiffness of the joints of the injured limb is habitually seen after 
fracture, and involves not only those of which the broken bone forms 
part but also those at a distance from it, especially on the distal side. 
It is most marked in the old and rheumatic and in joints directly in- 
volved in the fracture or coineidently sprained. It appears promptly 
after the accident, is most marked when the splints are removed 
(unless measures have meanwhile been taken to relieve it), and in 
most eases disappears slowly under use of the limb. If a joint is 
involved in the fracture, or otherwise injured at the moment oi' the 



78 FRACTURES. 

accident, a traumatic arthritis may follow and the resultant stiffness 
may be permanent ; and in the old and rheumatic more or less limita- 
tion of motion may remain even when the joint has not been directly 
injured. 

The causes of the stiffness, exclusive of direct injury of the joint, 
are to be found in injury of the muscles, oedema, and shortening and 
loss of elasticity in the peri-articular tissues, sometimes because of 
their implication in the irritative reaction following the injury, and 
sometimes because of the enforced quiet. This stiffness may be per- 
manent, in whole or in part, when the periarticular tissues are perma- 
nently shortened by cicatricial change, or when a muscle moving the 
joint has undergone marked fibrous cicatricial change or has become 
abnormally attached to the callus. This is more common in compound 
fractures that have suppurated than after simple fracture. Stiffness of 
the knee and ankle after fracture of the thigh, of the elbow after fracture 
of the arm, and of the wrist and fingers after fracture of the forearm is 
constant and often very persistent. It is relieved by measures which 
diminish the oedema and improve the circulation, and these may some- 
times be employed before consolidation of the fracture is complete : 
such are massage, passive motion, and position. The fingers stiffen, 
and sometimes very rebelliously, under immobilization, and especially 
when kept fully extended. The rule should therefore be, in all 
injuries of the upper extremities, to leave them free of the dressings 
whenever that is possible and to instruct the patient to move them 
frequently ; when they must be confined the position of flexion for 
the fingers and abduction for the thumb is to be preferred. 

Persistent active and passive motion of the joints within their ex- 
isting range, massage and hot and cold douching will usually increase 
the range and freedom rapidly ; in the young and young adults little 
time will be lost by simply trusting to the natural use of the limb to 
restore its functions. Patients should be encouraged to disregard 
pain following use which does not leave the joint tender the next day. 
Limitation of motion due to displaced fragments or overgrowth of 
callus can be relieved, if at all, only by operation. 

Atrophy of the Muscles. A limb that has long been withdrawn 
from use because of fracture appears smaller above the seat of the 
injury, and also below it if the oedema has disappeared. Advantage 
has been taken of the death of a few patients at this perio 1 to weigli 
their muscles, and they have been found distinctly, and in some cases 
notably, smaller than those of the opposite limb, the loss involving 
all and not merely those of some group supplied by a nerve that might 
have been injured. In the young and in young adults the loss is 
soon made good, but in others and in cases of long duration the 
atrophy may persist for months or even be permanent. Various 
explanations have been offered, such as lack of use, occlusion in fixed 
dressings, diversion of nutritive materials to form the callus, and reflex 
trophic disturbances from injured nerve branches, but none is free from 
serious objections. Massage, electricity, and systematic exercise are the 
measures employed to hasten or effect recovery. 

Thrombosis of the Veins and Embolism. Thrombosis of some of the 



COMPLICATIONS AND REMOTE CONSEQUENCES 70 

larger veins in the neighborhood of a fracture is thought to be rather 
common and to be the cause of the oedema and venous congestion 
which are so constant and troublesome after fracture of the lower 
limb when the patient begins to walk. Occasionally, but very rarely, 
the process occupies or extends into a vein sufficiently large to furnish an 
embolus which is carried to the heart or, more commonly, through it 
into the pulmonary artery, and causes death. Virchow published in 
1846 such a case following fracture of the neck of the femur, and 
Durodie" l collected eight other cases in which the deaths occurred be- 
tween the sixteenth and fifty-seventh days. One fracture was of the 
femur, the others of the leg. Wilde 2 reported two cases and collected 
five others; and Smirnow 8 reported one and collected thirty-seven 
reported cases. 

The symptoms are the usual ones of pulmonary embolism : sudden 
onset, with lividity or pallor, dyspnoea, precordial distress, and death 
in a few minutes. 

Arteries. Traumatic aneurysm is a rare complication. H. Meyer 4 
collected sixty reported cases and added one of an intercostal artery 
after fracture of a rib. Thrombosis of an artery, because of coincident 
bruising, is more common. 

1 Durodie : Etude sur les Thromboses et l'Embolie veineuses dans les Contusions et 
les Fractures, These de Paris, 1874, No. 326. 

2 Wilde : Centralb. fur Chir., 1902, p. 1349. 
3 Smirnow: Ibid., 1903, p. 825. 

* Meyer : Inaug. Dissert., Kiel, 1903 ; Centralb. fur Chir., 1903, p. 819. 



CHAPTER VII. 

TREATMENT. 

Reduction. Retention : Removable Dressings, Permanent Dressings, Direct Fix- 
ation. Massage. Ambulatory Treatment. Management of Joints. Com- 
pound Fractures. Amputation. Compound Articular Fractures. General 
Treatment. 

Generally speaking, the treatment of a fracture should begin 
when the patient is first seen, but by this it is not meant that every 
indication should at once be met by appropriate measures ; even the 
correction of the displacement, the " setting" of the fracture, and the 
immobilization of the fragments may have to be left undone or in- 
complete because of conflicting and dominating conditions, such as 
extreme swelling, muscular spasm, or associated lesions. A delay of 
even several days is usually, in respect of these indications, of small 
importance, for the preparatory work in the bone and soft parts goes 
on notwithstanding it, and when finally the adjustment is made the 
condition differs but little from that which would have existed had it 
been made at the first. 

A much more important indication in most cases is to prevent addi- 
tional injury while the patient is being taken home or to hospital. 
The danger at this time is that by incautious handling, disordered 
movements, or injudicious attempts to use an injured limb a simple 
fracture may be made compound or additional laceration caused. 
This risk exists especially after fracture of the leg because a large ex- 
tent of the surface of the tibia lies immediately beneath the skin and 
the end of a fragment can easily be forced through it. The surgeon 
therefore will protect the limb by a temporary splint, when such pro- 
tection is needed, and the judicious layman will leave the patient 
undisturbed or will transport him recumbent. 

If the fracture is one which necessitates confinement to the bed, the 
bed should be narrow and high, and the mattress firm. A long, broad 
board may be placed beneath the latter if the spring mattress is soft. 
Specially constructed " fracture-beds," some of which are very ingen- 
iously arranged, are convenient, but not at all essential. A water-bed 
or air-bed is of the greatest value in the treatment of fractures of the 
spine in minimizing the formation and duration of bed-sores. 

The points to be considered and the indications to be followed by the 
surgeon called to treat a fracture vary greatly in different cases accord- 
ing to the bone or portion of bone involved, the complications that 
exist or are to be feared, and the age, the health, the habits, and 
even the social status of the patient. At one end of the long and 
varied series of problems which present themselves he lias only to 

80 



TREATMENT. 81 

provide the simplest means to protect the patient from additinal in- 
jury or pain during the few days or weeks that are needed for repair; 
at the other the highest resources of his art are required to save life 
or limb or to preserve function. On the one hand, the fracture may 
be the sole thing to be considered, his attention must be unremittingly 
given to the position of the fragments and their maintenance in proper 
relations, and his skill and care will determine the character of the 
result ; on the other, his best endeavor may be powerless to affect the 
position of the fragments or modify the result, or the fracture, as 
in many of the base of the skull, may be a wholly unimportant and 
negligible incident beside the associated lesion. 

The indications for treatment arise, therefore, in varying degrees 
from the fracture itself, the associated lesions, and the immediate or 
late local or general effects upon the patient. Occasionally they con- 
flict, and the surgeon must then temporarily disregard some or he must 
even be content with a defective local result because an attempt to 
secure a better one would involve risks disproportionate to the advan- 
tage sought. Those directly concerned with the fracture are to cor- 
rect displacement of the fragments, if such displacement exists and if 
its correction is possible and advisable, and to oppose by appropriate 
means the action of those forces which might reproduce it, such as 
muscular action, swelling, and gravity. This correction of the dis- 
placement is termed the "reduction" or " setting" of the fracture. 

Reduction. 

Not every fresh fracture is accompanied by a displacement that needs 
to be corrected ; and of those in which such displacement exists, in 
not every one is reduction possible or advisable; and sometimes when 
reduction is both possible and advisable circumstances require that it 
should be delayed. 

Fractures without a displacement that needs to be corrected are 
many and varied, such as most simple fractures of the cranium, of the 
scapula, of the ribs, the ilium, the shaft of the fibula or ulna alone, 
and many of the metacarpal and metatarsal bones. 

Keduction is said to be impossible (although in most cases the better 
term would be inadvisable) when the opposing conditions are such that 
they cannot be overcome by the methods ordinarily in use, and when 
more efficient ones would involve overbalancing disadvantages or 
risks. The causes of this condition are varied ; among them may be 
mentioned the interlocking of the irregular ends of the main frag- 
ments, the interposition of soft parts or small fragments, and the small 
size and inaccessible position of a fragment, as in some articular frac- 
tures. When the fracture is of the shaft or subcutaneous end of a 
long bone the existence and character of the displacement are usually 
recognizable, but when one of the principal fragments is a part of the 
articular end of a long bone and is thickly covered by muscle or 
masked by swelling, not only the character but even the existence o( 
the displacement may be in doubt and remain so until after repair is 

far advanced. In such cases an exact diagnosis can be made ami 
6 



82 FRACTURES. 

reduction can generally be effected by the aid of an incision which 
exposes the seat of fracture, but although the probability that such an 
operation in experienced hands and under proper precautions would 
be followed by disaster is small, yet the evils of such a result, if it 
should follow, are usually so in excess of those resulting from the 
persistence of the displacement that the operation is rarely undertaken 
while the injury is recent, and then only because of the presence of 
some controlling condition or danger, such as pressure upon the skin 
or a main vessel or nerve that cannot otherwise be removed. In cases 
not thus complicated the w T orst that can follow after fracture of the 
shaft is failure of union or union with a disabling deformity, and both 
of these conditions may be relieved by a late operation. Nevertheless, 
displacements unrelievable by manipulation and likely to involve 
serious loss of function if not corrected, can occasionally be recog- 
nized, and in such cases reduction by open operation is called for. 
They are generally cases in which the limb has been greatly distorted 
at the time of the accident, so that the sharp end of a fragment has 
been driven into an adjoining muscle or through the enveloping fascia, 
or an obliquely broken fragment has been forced around to the opposite 
side of the other from which it has been broken. The first form is not 
uncommon in fractures of the lower end of the femur or in the neigh- 
borhood of thinly covered joints. From the admitted propriety of 
operative interference in such cases it is a long step to similar inter- 
ference in all, as has been urged ; and such generalization, if accepted, 
would, in my judgment, lead to disasters far more serious and numerous 
than the disadvantages that would follow failure to reduce the displace- 
ments. Ranzi l reports 4 severe infections in 50 operations and pro- 
tests against the generalization of reduction by operation, Tuffier, quoted 
by Bardenheuer, 3 in 22, Korte, 2 in 4. See also Fritz Konig 2 for a 
thoughtful study of the conditions justifying or forbidding operation, 
and a valuable paper on the late results after fracture of the femur by 
Ashhurst and Newell. 3 

The reasons advanced by those who favor reduction by operation and 
mechanical fixation by suture or pins as a general practice are that by 
this means alone can complete reduction be made and maintained and 
failure of union certainly prevented. To this the reply may be made 
that failure of union is rare, and that in most cases it is due to a general 
cause and not to a local one which can be removed by operation, and 
that when such local cause exists the fact is usually apparent and is 
then a proper reason for operating. Further, that even if exact reduc- 
tion is made by operation the use of sutures or pins to maintain it is 
not only ineffectual but is also in itself objectionable, because it may 
cause delay and even failure of union by exaggerating the rarefactive 
process which precedes repair and delaying or preventing the productive 
osteitis which alone can complete it. The wire suture breaks or be- 
comes loose, pins loosen, so that for effective support during repair we 

1 Ranzi: Arch, fur klin. Chir., vol. 80, pp. 567 and 843. 

* Konig : Ibid., vol. 76, p. 725. 

3 Ashhurst and Newell : Annals of Surg., Nov. 1908. 



TREATMENT. 83 

must still depend upon the same external means that are used when no 
operation is done. Irregularities in the union rarely cause any inter- 
ference with function, and diminish as time passes, especially in the 
young. Recent observations by Konig 1 have shown most remarkable 
corrections thus effected, within three or four years after the fracture, 
of displacements which would have been thought to ensure conspicuous 
deformity and disability. Finally, the additional injury to the peri- 
osteum, which is apparently inevitable in the exposure of the bone for 
drilling, delays union and facilitates later displacement ; and the injury 
done to the muscles, if the knife has to pass through them to expose 
the bone, is liable, perhaps likely, to restrict the mobility of the cor- 
responding joint through cicatricial change in the muscle or its attach- 
ment to the callus. It seems to me clear that operation should be 
reserved in fractures of the shaft for those cases in which it is clearly 
indicated by some marked and otherwise irreducible displacement, and 
that for the maintenance of reduction thus made reliance should be upon 
external support without metallic sutures or pins placed in the bone ; 
at the most, a temporary silk or an absorbable suture may be used. 
Most German surgeons appear to be against such generalization of oper- 
ation ; in England Lane, in France Tuffier, and in the United States 
Huntington, have written in favor of it. 

In articular fractures the conditions are different : the displacement 
if uncorrected may seriously compromise the usefulness of the joint, 
and but little if any relief is to be expected from a late operation. 
If anything is to be done it must be while the injury is still recent. 
I have taken this course in a considerable number of cases, and with- 
out ill result in any, but I am convinced it should be resorted to only 
after thorough study of the conditions and careful weighing of the 
probabilities. The risk of such primary interference by operation is, 
I think, less the more promptly it follows upon the receipt of the 
injury : if it is done within the first twenty-four hours the condition 
is practically that of an operation upon previously uninjured tissues, 
and the same confidence may be felt that primary union will be 
obtained, but if the third or fourth day has been reached and the tis- 
sues are swollen and infiltrated with extravasated blood the same con- 
fidence cannot be felt, and it is, I think, better to wait for the subsi- 
dence of the swelling and the absorption of the blood. 

Other conditions which make exact and immediate reduction inad- 
visable are crushing of the spongy tissue of the bone, extreme sub- 
fascial swelling of the broken limb, muscular spasm, and coincident 
injuries or other conditions which prevent the application of a dress- 
ing efficient to maintain the reduction when effected. Crushing of 
the spongy tissue is seen mainly in the old, at the upper end of 
the femur and humerus, at the lower end of the radius, and in the 
bodies of the vertebra\ The effect of this crushing is the same 
as the removal of a piece of the bone; if the fragments are restored 
to their original positions a gap corresponding to the amount of the 

1 Konig-: Arch, fur klin. Chir., 1908, vol. S5, p. 187. 



84 FRACTURES. 

crushing is created between them, which, if the position is maintained 
must be filled by the production of new bone, a task that may be 
beyond the power of the organism, and failure in which would lead 
to failure of union, a result much more disabling than the persistence 
of the deformity. 

Extreme subfascial swelling of an injured limb shortens it and in- 
creases its transverse diameter, because the capacity of the fascial 
sheath is greater the more nearly it approaches the globular form ; 
consequently forcible elongation of the limb with the object of cor- 
recting the shortening diminishes the capacity of the fascial sheath 
and increases its tension and the pressure upon its contents ; this 
resistance may be sufficient to maintain the shortening against any 
reasonable effort to overcome it, or to endanger the vitality of the 
limb by interference with the circulation. It is therefore necessary 
to await the subsidence of the swelling. 

Muscular spasm, excited by the trauma or by pain or the fear of 
pain, acts powerfully at first to fix the fragments in their faulty 
positions and especially to produce and maintain shortening of the 
limb. It usually disappears within a day or two, and can be tempo- 
rarily annulled by anaesthesia or a full dose of opium or by deep injec- 
tion at the fracture of J-l grain of cocaine in weak solution. 

Associated injuries or conditions which prevent or delay reduction 
may be general or local, such as profound shock due to the fracture 
or to other injuries, damage to the main vessels of the limb threaten- 
ing gangrene, and extensive wounds of the skin which would prevent 
the use of dressings to maintain reduction. 

In the absence of any of these contraindications the sooner the 
fracture is " set," the sooner the fragments are brought to and fixed 
in the positions they are expected to keep during repair, the better; 
for although the preparatory changes in the bone itself require several 
days, and in places even weeks, for their completion, yet the accessory 
processes in the soft parts begin immediately, and it is desirable that 
they should not be interrupted or undone by changes of place and 
relations. The thickening and infiltration of the parts adjoining the 
bone which appear so promptly give a steadily increasing fixity to the 
position of the fragments, and it is desirable that that position should 
as early as posible be made the permanent and final one, for although 
it can be changed without much difficulty and to a considerable extent 
in many fractures even two or three weeks after the receipt of the 
injury, yet the shift is necessarily accompanied by some loss of security 
and time. 

The actual reduction or setting of the fracture is in many cases a 
procedure guided only by general ideas, not by an exact and detailed 
knowledge of the peculiarities of the displacement to be overcome or 
even of the lines of fracture, and the extent to which the effort has 
been successful can only be surmised, not positively known. Such is 
notably the case in fracture of the shaft of a long bone thickly covered 
with muscle, as the femur. By eye, touch, and measurements the 
surgeon can recognize shortening, angular, rotatory, and perhaps even 
lateral displacement, and by traction and pressure he can straighten 



TREATMENT. 85 

and lengthen the limb, but he cannot know whether or not the adjust- 
ment of the fragment is accurate and close. The same is measurably 
true even of many fractures of bones that are more or less subcuta- 
neous and palpable ; or if palpation shows some remaining irregularity 
of outline the best effort may be unavailing to correct it. This, 
however, does not make the result so much a matter of chance as the 
statement may seem to indicate ; the main factors of displacement at 
the different points are known, and the surgeon is safely guided by 
this knowledge in his choice and use of methods to make and main- 
tain reduction and of the attitude and support given to the limb while 
the fracture is healing, and is justified in awaiting the outcome with 
a confidence that is limited only by knowledge of the fact that in a 
certain proportion of cases, fortunately small, unknown and unknow- 
able factors may defeat efforts wisely conceived and faithfully ex- 
ecuted. The ideal is the complete restoration of form and function, 
but he must often be content to obtain, or even to seek, much less. 
These more or less necessary limitations will be mentioned in connec- 
tion with the results of the individual varieties of fracture. 

Since the principal causes of displacement after fracture of the shaft 
of a long bone are the tonic contraction of the attached muscles and 
the unsupported weight of the lower segment of the limb, reduction 
is commonly effected by bringing this lower segment into line with 
the upper one and making steady traction upon it in the direction of 
its long axis, the different joints being usually held in partial flexion 
in order that the attached muscles on either side may be correspond- 
ingly relaxed. Note must be taken, in fractures at certain points, of 
the known tendency of the upper segment to assume a certain attitude 
because of the unopposed action of the muscles attached to it, an atti- 
tude which is often but faintly indicated by the form of the limb if 
the fragment is short and thickly covered by muscle. Common ex- 
amples are furnished by fractures of the upper third of the femur and 
of the surgical neck of the humerus, in both of which the upper 
fragment may be markedly abducted, flexed, and rotated outward. 
The surgeon confidently places the lower segment in the corresponding 
attitude, even if he cannot detect the deviation of the upper one, for 
he knows that even if it does not exist the upper fragment will follow 
the movement he gives to the lower one, and the two pieces will be 
in line when he makes the traction designed to give the limb its proper 
length. 

While traction (and, if necessary, rotation of the lower segment) 
is made the surgeon makes lateral pressure to correct such lateral dis- 
placement as may remain, and seeks to discover and take advantage 
of such peculiarities of the line of fracture as may aid him to main- 
tain the position he gives the fragments. Thus, in a transverse frac- 
ture or in one with marked irregularities of outline the opposing ends 
may be so engaged with each other that the lower fragment will be 
held in place and kept from overriding, notwithstanding the pull of 
the muscles. If there is only an angular displacement, as in partial, 
subperiosteal, and some transverse fractures, traction is not needed, 
and the surgeon has only to correct the deviation by lateral pressure. 



86 FRACTURES. 

In the partial fractures of adolescence this sometimes requires con- 
siderable force; the knee must be placed against the projecting angle 
and the ends drawn into line ; but usually it can be accomplished by 
the hands alone, the thumbs being placed against the angle while the 
fingers grasp the limb above and below it. 

A serious obstacle to reduction occasionally arises from the penetra- 
tion of the overlying muscle and fascia by the sharp end of one of the 
fragments, usually the upper one. This occurs most frequently in 
oblique fracture of the lower third of the femur, and can there be 
treated most effectively by flexing the hip and the knee to a right 
angle, thus drawing the relaxed quadriceps (which is the muscle com- 
monly penetrated) downward past the engaged end of the upper frag- 
ment, and, if necessary, completing the act by traction at the knee. 
This exemplifies the principles of treatment in all cases : relaxation 
of the muscle, if it crosses the proximal joint, and also the fascia by 
moving the limb toward the corresponding side ; drawing the muscle 
downward by bending the distal joint in the opposite direction ; and 
then lifting the lower segment of the limb bodily away from the upper 
fragment. If this or other appropriate manipulations fail, the frag- 
ment must be exposed by an incision and freed by direct means. If 
the fragment has perforated the skin also the opening should be at 
once enlarged and reduction guided and aided through it ; as the exter- 
nal wound exists, nothing is lost and much may be gained by freely using 
it for reduction, cleaning, and drainage. 

Whenever an anaesthetic is given it is prudent to protect the broken 
limb during its administration by temporary splints or the hands of 
an assistant in order that the lacerations may not be increased by the 
unconscious struggles of the patient. 

In some cases of fracture at the border of, or just within, the ex- 
panded spongy end of a bone, where the fragments are interlocked or 
impacted, as in some Colles' fractures at the lower end of the radius or 
in supracondyloid fracture of the lower end of the humerus in children, 
it is advisable to increase the irregular displacement as a first step, and 
forcibly to press the epiphyseal end downward away from the shaft so 
as to free it, and then, correcting the lateral displacement by pressure, 
to turn the fragment into line ; and sometimes the small epiphyseal 
fragment has to be moved forward and backward forcibly so as to break 
up the fine interlocking. 

Under similar circumstances the epiphyseal fragment can sometimes 
be brought into place by so changing the attitude at the corresponding 
joint as to make tense a portion of the capsule which is attached to it 
and then by continuing the movement to correct the displacement, or 
by making direct traction upon it through its ligaments. In some 
injuries — e. g., separation of the upper epiphysis of the humerus and 
Pott's fracture at the ankle — the character of the displacement is so 
constant that a formula of treatment is based upon these facts ; similar 
formula? have been made for injuries at other points, as the elbow and 
knee, but the lesions and displacements are there too varied to make 



TREATMENT. 87 

routine treatment safe. At the shoulder the separated epiphysis is in 
anterior flexion and abd notion although the arm hangs by the side ; 
on raising and abducting the elbow the movement of the already flexed 
and abducted epiphysis is promptly arrested at the normal limit by the 
posterior portion of the capsule, and then the lower portion of the 
humerus is brought into line with it by continuing its movement in the 
same direction, and thus the angular displacement is corrected. At the 
elbow, after fracture of the internal condyle, the small fragment can be 
drawn down into place by full extension of the joint and abduction of 
the forearm ; and after supracondyloid fracture of the humerus full 
flexion of the elbow, by making tense the posterior portion of the cap- 
sule, enables the surgeon to correct an angular displacement of the lower 
fragment in which the apex of the angle is directed forward. 

Retention. 

The objects of retention are to prevent displacement of the frag- 
ments by the various agents that are competent to produce it, notably 
gravity and muscular contraction, to protect the limb from external 
violence during the progress of repair, and to prevent the pain that 
would be caused by movement of the fragments. The relative im- 
portance or urgency of these needs varies greatly in different cases, 
and this, together with the mechanical conditions, measurably deter- 
mines the choice of the method of treatment. Thus, in the fracture 
of a single long bone, such as the femur, where the weight of the 
limb and the action of the muscles are efficient and always ready to 
produce displacement, support equivalent to that destroyed by the 
injury must be supplied by apparatus; while in fractures of only one 
of two or more parallel bones, as of the fibula or of a rib, or in those 
of the flat or small spongy bones, or of an apophysis or condyle, only 
such a dressing is required as will moderate or prevent voluntary or 
involuntary contraction of attached muscles. 

The swelling of a limb which so promptly follows its fracture is an 
element of much importance because its variations affect the adjust- 
ment and fit of most dressings and because its appearance after the 
application of a dressing that envelops a limb may so interfere with the 
circulation as to cause gangrene of the limb or ischemic degeneration 
and contracture of the muscles. For these reasons it is frequently 
advisable to delay the application of an enveloping permanent dressing 
until after the swelling shall have notably subsided, and it should be the 
rule to make frequent examination of the fingers and toes during the 
first two or three days after the application of such a dressing, and to 
leave them uncovered by the dressing for the purpose of such exami- 
nation. 

The possibility of dangerous constriction is specially to be borne in 
mind in dressings which completely and closely encircle a limb and 
which are inelastic, such as plaster-of- Paris encasement or even a 
muslin roller-bandage applied directly to the surface without an inter- 
vening layer of cotton. Such a dressing snugly applied while the 



88 FRACTURES. 

injury is recent will almost always become too tight and will have to 
be removed in a few hours either because of the pain which it causes 
or of the threatening strangulation of the tissues. This is true even 
when the injury is a comparatively slight one. I have seen gangrene 
of the hand and forearm follow the application of a gypsum dressing 
for fracture of the olecranon. A roller-bandage may be placed directly 
upon the limb below the fracture to restrain its swelling, but should 
not be carried as high as the fracture beneath the splints, except very 
loosely ; and when splints are used they should be broad enough to 
prevent circular constriction by the bandage which binds them in place. 
If plaster of Paris is used it should preferably be in the form of 
moulded splints, not complete encasement, or at least in a form which 
will permit the dressing to be loosened. 

It is a good rule also to remove a permanent dressing after ten or 
twelve days in order to detect and correct any displacement that may 
have taken place under it and to tighten or renew it to meet the 
shrinking of the limb. 

It is specially important that the possibility of constriction by the 
dressing should be guarded against whenever the injury is such 
that it may itself cause gangrene of the limb. A limb whose vitality 
has thus been put in doubt by the injury should be treated for the 
first few days with the primary object of favoring the impaired cir- 
culation and especially of avoiding the creation of any additional ob- 
stacle to the venous flow, and this not only for the advantage of the 
patient, but also for the protection of the surgeon against the suspicion 
or the charge that his dressings may have caused the gangrene. This 
disastrous result of injury is a fruitful source of suits for malpractice, 
and the defence that it was due to the injury and not to the treatment 
is usually viewed with so much suspicion that the surgeon should be 
watchful from the beginning of the case that the real cause should be 
clear. It must be remembered that in the great majority of cases 
the gangrene is of the moist form and due to interference with the 
venous flow, and that this interference may easily and rapidly be 
raised to a dangerous degree by circular constriction at even a single 
point. 

Cases differ far too widely in severity and local conditions to permit 
of a general rule of practice applicable to all. Many, in which the 
tendency to displacement is slight or easily controlled, may be treated 
in a permanent dressing from the beginning, one which gives the nec- 
essary support without danger of constriction, and can be left in place 
(or removed temporarily for inspection) for one, two, or three weeks. 
Others, more severe, such as most fractures of the femur, also receive 
a permanent dressing at the beginning because this dressing is mainly 
applied below the seat of fracture and does not expose to constriction 
by swelling. Others, such as most fractures of the leg, should rest in 
a temporary dressing, such as a Volkmann splint, for from five to 
ten days, unless permanent moulded splints that can be loosened are 
used. 

So, too, when the surface of the limb has been so torn or bruised 
that the wounds cannot be properly treated through an opening made 
for the purpose in a permanent dressing, and when damage to the 



TREATMENT. SO 

deeper parts forbids the use of any constriction or pressure. Under 
such circumstances the surgeon must be content to make such dressings 
as the associated injuries require and to leave the limb simply sup- 
ported upon the bed by pads or in splints loosely applied over the 
other dressings. Although the use of these temporary dressings may 
be necessarily prolonged for several weeks, it will be convenient and 
proper to describe them under that title. 

The presence of large blebs is sometimes an additional reason for 
delay, although they usually heal promptly under a protective dress- 
ing after puncture. If it is desired to leave the limb as undisturbed 
as possible, it is advisable thoroughly to clean and disinfect the ad- 
joining skin, cut away all the raised epidermis, cover the exposed sur- 
face with sterile rubber tissue or silver foil, and apply a gauze dressing. 

Temporary and Eemovable Dressings. 

The object of a temporary dressing is mainly to protect the patient 
against pain and additional injury by movement of the fragments 
during transport to his home or hospital, or to prevent displacement 
by the unsupported weight of the lower segment of the limb ; it is 
rarely efficient to prevent displacement by the action of the muscles 
when the character of the fracture is such that such displacement is 
possible. 

Side Splints. These are usually made of wood, but in case of need 
many other materials are available, such as card-board, stiff leather, 
iron, zinc, tin, even bundles of tightly-rolled straw. 

The wooden splint in its simplest form is a piece of soft wood of a 
length and breadth corresponding to those of the injured limb and 
thick enough not to bend under firm pressure. A thick layer of 
cotton or other soft material should be bound along the side which is 
to rest against the limb, and should be reinforced at needed points in 
order to fill depressions of the surface of the limb. Projecting points 
of bone should be protected by cotton placed around them, not upon 
them. While an assistant makes traction upon the lower segment of 
the limb the surgeon places the splints, one on each side, and binds 
them on with a roller-bandage, taking care that the turns support the 
limb throughout its entire length, but do not make circular compres- 
sion. The splints should be long enough to support the hand and 
foot respectively. A form in common hospital use is the thin bass- 
wood splint, the necessary rigidity being obtained by binding several 
together. 

Gooch's flexible wooden splint, which is made of narrow strips pasted 
together upon cloth on one side, is designed to adapt itself to the curve 
of the limb and thus give a more uniform support. It is rarely used. 

The carved splints sold in packages of assorted sizes have few if 
any points of superiority over those improvised for the occasion, for 
they also need to be fitted and padded. Tf it is desired to have a 
splint that more 4 nearly follows the contour of the limb an excellent 
one can be made with plaster of Paris (see below) or card-board or 
leather softened in water, and similar ones can also be used with ad- 



90 



TREATMENT. 



vantage over the dressings that are needed for associated wounds of the 
skin or compound fractures. 

Splints of wire that can be measurably modelled to the limb are con- 
venient ; they can be had from the instrument makers. 



Fig 




Petit's fracture-box. 



The fracture-box (Fig. 33) is a form of wooden splint once much 
used in fractures of the leg, but now almost wholly discarded for the 



following : 



Fig. 34. 




Volkmann's splint for leg. 



Volkmann's splint (Fig 34) is a shallow gutter and foot-piece, made 
in several lengths, and fitted with a movable support, by which the 
foot can be raised from the bed. For use it is thickly padded with 
cotton, and the leg is bound in it with a roller-bandage. Care must 



TREA TMENT. 



91 



Fig. 35. 



be taken that undue pressure is not made on the skin covering the 
front of the tibia by the bandage or on the heel or the tendo Achillis ; 
the latter pressure is best avoided by slinging the foot by means of a 
broad strip of adhesive plaster extending from the middle of the calf, 
under the heel and along the sole, to the top of the foot-piece, where 
it is made fast by a reversed piece attached to it and then to the lower 
surface of the metal. 

Gutters of galvanized wire or tin (Fig. 35) are much used for frac- 
tures of the humerus : they give more protection than short splints 
because they include the forearm. They can be readily made from 
sheets of wire gauze by taking a strip of suitable size and cutting it 
partly through at the angle, and tying together the meshes which over- 
lap where it is bent. 

When it is desired to cover the limb with dressings because of the 
presence of a wound of the skin or to make moderate uniform com- 
pression, or while waiting to 
learn the effect of the injury 
upon the vitality of the skin or 
the limb, a convenient method 
of applying them so that they 
can be readily and painlessly 
removed for adjustment or in- 
spection is in the form of the 
Scultetus bandage, a dressing 
which was formerly in wide use 
for retention. The dressings 
are cut in thick strips one-half 
longer than the circumference 
of the limb and three or four 
inches wide, and then arranged 
upon a piece of muslin a little 
longer than the part to be 
dressed in such a way that each overlaps its adjoining upper one by 
about an inch. The limb is then placed along the centre of the band- 
ages and each end of each of the latter, beginning with the lowest, 
turned over the front of the limb until it is entirely enveloped ; lateral 
support is given by splints rolled into the sides of the underlying strip 
of muslin and bound fast, or by other splints, or by placing the limb in 
a Yolkmann splint or a gutter. The front and sides of the limb can then 
be readily exposed by turning back the ends of the pieces of dressing. 

Instead of lateral, anterior or posterior splints may be used, either 
that they may be combined with suspension or that portions of the 
limb may be more conveniently exposed and dressed. Because of 
the importance of equally distributing the pressure, a posterior splint 
to be used with suspension should be accurately fitted to the limb ; 
consequently the moulded splints (plaster of Paris, gutta-percha, etc.. 
see below) are to be preferred. When they are sufficiently rigid the 
limb can be suspended by two or three bandages passed beneath and 
attached above to a suitable support. 




Wire gutter for the arm and forearm. 



92 



FRACTURES. 



Late iu the treatment of fracture of the femur one of the forms of 
hip-splints may be conveniently used. 

Anterior suspended splints may also be of the moulded kind, with 
included metal rings or loops for the attachment of the supporting 
cords, or some modification of Nathan R. Smith's anterior splint 
specially designed for the treatment of fractures of the femur. This 

Fig. 36. 




Suspended moulded splint for fracture of leg or lower part of femur. 

splint (Fig. 37) is made of two parallel iron rods, joined at the ends, 
and by two or three intermediate rods, bent slightly at the knee and 
sharply upward at each end to fit the foot and pelvis. It is placed 
along the anterior surface of the limb, which is attached to it by a 



Fig. 37. 




Nathan R. Smith's anterior splint. 



roller or by straps, suspended by cords. Its primary idea was, appar- 
ently, as a substitute for the double-inclined plane ; it has practically 
been abandoned for fracture of the thigh in its original form and method 
of use, and its place taken by modifications which combine traction 



TREATMENT. 93 

with suspension. ( Vide infra.) When used, it should be less bent 
than as shown in Fig. 37, and the leg horizontal. 

Moulded splints are constructed of any material that can be made 
temporarily soft enough accurately to take the shape of the part to 
which it is fitted and which then becomes hard enough to retain the 
shape thus given to it. The materials most frequently used are 
plaster of Paris, pasteboard, leather, felt, and gutta-percha. 

Pasteboard is used by softening one or two strips of suitable size by 
immersion in hot water, and then moulding them to the limb by 
binding them on snugly with a roller-bandage. Temporary support 
must usually be given by other splints until the pasteboard has be- 
come hard by drying. When it is necessary to bend the pasteboard 
at a sharp angle cuts should be made in it in suitable directions and 
places and the overlapping portions stitched together. 

Leather and felt are prepared in the same manner. A material is 
made for this purpose of woven tissue soaked in shellac which can be 
softened by dry heat and hardens more rapidly than the others. 
Gutta-percha is used in strips one-sixteenth to one-eighth inch thick 

Fig. 38. 




Posterior gypsum splint or gutter. 

and is softened by immersion in hot water. The stickiness of the 
surface can be mitigated by covering it with muslin. 

Plaster-of-Paris, or gypsum, splints can be made of the prepared 
bandages or of some loose-meshed material soaked in plaster cream. 
If the prepared bandages are used they should be thoroughly wet in 
the usual way, squeezed out, and then rapidly unrolled back and forth 
to make a splint of the desired dimensions. From eight to fifteen 
layers are required to give the needed solidity. Plaster cream is pre- 
pared by sifting the dry plaster into water and then spreading the 
plaster thus moistened upon the selected material previously cut to 
suitable shape and wrung out. in water. The number of layers 
needed will depend upon the thickness of the material, and care must 
be taken thoroughly to work the plaster into them. The use of hot 
water or the addition of salt or zinc oxide to the water will hasten 
the setting. If the plaster has been long exposed to the air before 



94 



FRACTURES. 



use it should be dried in an oven ; otherwise the setting may be long 
delayed or even fail. Splints thus prepared can be made impervious 
to water by varnishing them or by pouring melted paraffin upon 
them. A strip of rubber tissue or oiled-silk carefully packed in at 
the exposed point will protect satisfactorily for several days from the 
discharge of a wound. Weight can be reduced, while preserving the 
strength, by inserting thin strips of metal or wood at places where 
the splint will not require much modelling to fit the limb. Splints of 
this kind are specially useful in fractures at the ankle, wrist, elbow, 
and arm, and not infrequently, such a temporary splint will remain 
efficient for two or three Aveeks. For fractures of the leg one of the 
splints should be posterior and broad enough to cover nearly half of 
the circumference of the limb ; a narrower anterior one may be used 
Fig. 39. with it, or a lateral one the lower end of 

which encircles the instep, or a bilateral one 
crossing below the instep like a stirrup. 
The posterior splint should pass along the 
sole and project about an inch beyond the 
toes so as to take the weight of the bed- 
clothing. They must be snugly moulded to 
the limb with a roller bandage, and the de- 
sired position of the fragments maintained 
by the hands or a suitable support until the 
plaster shall have set. 

If for any reason a posterior splint cannot 
be used, a strong broad anterior one may be 
substituted, and if suspension is desired the 
inclusion within it of a stout wire bent into 
loops at several points will facilitate it (Fig. 
36). 

A form of bilateral moulded splint which 
I have found convenient in fractures of 
the leg as a substitute for the Volkmann splint during the first week, 
and, because of the ease with which it can be removed, even for the 
complete encasement in plaster of Paris which usually follows, is the 
following : Two pieces of muslin are cut to the shape shown in Fig. 39, 
and of a size to fit the limb, and stitched together along the median 
line. Then twelve or fifteen pieces of crinoline, or three or four of can- 
ton-flannel, each a little smaller than a lateral half of the first, are 
soaked in plaster cream and laid in each half of the first between its 
two layers, and the whole then bound smoothly to the limb with a 
roller-bandage. Swelling of the limb is met by loosening the band- 
age, and inspection is easy by turning down either lateral half, the 
line of stitching acting as a hinge. The additional trouble entailed in 
its preparation, as compared with the Volkmann splint and later encase- 
ment in plaster, is offset by the greater security and ease with which the 
patient can be moved during the first week, and the ease with which 
the dressing can be removed and the seat of fracture inspected so long 
as intercurrent displacement is possible and corrigible. 




Stocking or bivalve plaster splint. 



TREATMENT. 95 

Permanent or Final Dressings. 

The dressings included under this title are those designed to main- 
tain the fragments in the relative positions given them until union is 
complete or, at least, far advanced. They are expected to give the pro- 
tection and quiet of the temporary dressings, and in addition to oppose, 
with as much efficiency as possible, shortening of the limb or angular 
displacement by muscular contraction or gravity. As has been said, 
the temporary dressings may sometimes be used equally well for the 
same purpose, and some of the permanent dressings, especially those 
making continuous traction, may be used from the beginning. A 
rule of practice which will save the surgeon an occasional and very 
disagreeable surprise and disappointment should be to examine about 
the end of the second week, and again later if the fragments are still 
movable, every fracture that has been covered by the dressing in order 
to detect and correct such displacement as may have occurred beneath 
it. This applies especially to fractures of the shaft of the long bones 
and to some articular fractures in which displacement is easy. 

Fig. 40. 




Encasement of leg in plaster of Paris. 

. Complete encasement in plaster of Paris (Fig. 40), occasionally advis- 
able, if carefully watched, even as a primary dressing, is most useful 
and efficient when applied after the swelling has subsided, and at still 
later stages in cases in which continuous traction has been used until 
union has become well advanced. Its mode of application is as fol- 
lows : The limb is raised by one or two assistants who make steady 
traction upon it in order to keep it straight and of full length, the sur- 
geon wraps it in a thin layer of cotton batting, preferably prepared in 
three-inch rollers, and then applies the plaster roller-bandages, thor- 
oughly wetted and wrung out in hot water, from below upward. The 
turns of the-first layer should be drawn just tight enough to keep their 
place, and the subsequent turns simply rolled over the first without 
increasing the pressure, taking care to model the dressings accurately 
to the prominences and depressions of the limb. When the dressing 
is complete the limb is lowered to rest, and proper support given it 
until the plaster is hardened. The dressing should extend far enough 
above and below the fracture to rest against such prominences of the 
skeleton or muscles as may be present and will act, after the plaster 
shall have set, to prevent movement of the limb within its ease. When 
such fixed points do not exist, as at the shoulder and hip, other mean- 
to prevent shortening must be used, usually some form ot' traction. 



96 



FRACTURES. 



The upper and lower ends should be so placed that their edges will not 
make irritating pressure directly against a diverging surface ; thus, for 
the forearm it should stop well short of the flexure of the elbow or 
should pass a short distance up the arm ; at the ankle it should stop 
short of or pass well forward on the dorsum of the foot ; on the inner 
side of the thigh it should not reach the perineum. 

The finger or toes should always be left uncovered and should be 
repeatedly inspected during the first two or three clays in order to detect 
any interference with the circulation. 

In the lack of plaster rollers the dressing can be made of any 
coarse material cut in suitable strips and soaked in plaster cream. 

If it is desired to have a small portion of the limb exposed, as for 
the dressing of a wound, a fenestra can be cut, and its edges protected 
with adhesive plaster, rubber tissue, or oiled silk. If a larger opening 
is required the splint must be reinforced by one or two curved iron 



m 



the 



dressing 



bands incorporated 
additional turns of a 
dressing has hardened, 
opening includes the 
(Fig. 41). 

Ochsner recommends very highl 
protection of the splint 



or, better, fastened to it by 

plaster roller after the main portion of the 

These are termed " fenestrated " or, if the 

entire circumference, "interrupted" splints 



a means devised by Croux for the 
gainst the discharges in compound* fractures. 



Fig. 41. 




Fenestrated plaster dressing. 



It consists of a thick solution of India-rubber in chloroform mixed 
with small pieces of lambs' wool ; this is poured in between the splint 
and the limb around the opening. 

Similar dressings can be made with silicate of soda or potash, starch, 
dextrin, or glue. The silicate and dextrin are used by thoroughly satu- 
rating roller-bandages with the material and applying them in the same 
manner as plaster bandages. They do not dry so rapidly as plaster, 
but are lighter and cleaner and not so liable to crumble at the edges. 
Silicate is frequently used for dressings of the hand and forearm. 
The edges of both silicate and plaster dressings can be advantageously 
protected against crumbling by covering them with adhesive 
plaster. 



TREATMENT. 



97 



The removal of one of these dressings is a tedious and troublesome 
task ; it can best be done by cutting lengthwise with a short, stout- 
bladed knife, aided in the case of plaster by moistening the dressing 
along the line of the division. The diminished resistance to the knife 
gives warning of the proximity of the skin, and the deepest layer and 
the underlying cotton should be cut with strong bandage scissors. The 
principal difficulty is in turning re-entrant angles, as at the front of the 
ankle or elbow. After the division has been completed the sides can be 
forcibly drawn back and the limb lifted out. 

In cases in which the absence of firm points of support makes a 
fixed dressing inefficient effectually to oppose the contraction of the 
muscles, as in most fractures of the thigh and many of the humerus, 
permanent moderate traction is employed to tire the muscles and 
obtain and maintain the desired length of the limb. For this purpose 
the partially unsupported weight of one segment of the limb may be 
utilized or a weight attached to the lower segment. 

Traction by Weight and Pulley, or Elastic Traction. This method is 
employed almost exclusively in the treatment of fractures of the 
thigh. Methods of treatment by continuous traction have long been 
in use, but the efficiency and comfort which now make the method so 

Fig. 42. 










Adhesive plaster and "spreader" for Buck's extension. 

popular date from the introduction about the year 1850 by the Ameri- 
can surgeons Sargent, Josiah Crosby, and Gurdon Buck of the use of 
adhesive plaster to attach the weight or screw to the limb. Previously 
the attachment was by bandages about the foot and ankle, and the 
pain and damage to the skin occasioned thereby were such that efficient 
traction could not be maintained. 

"Buck's Extension." (As for a fracture of the thigh.) Two strips 
of stout adhesive plaster, each four inches wide and long enough to 
reach from well above the knee to a little beyond the sole, are notched 
on each side at the junction of the lower and middle thirds for one- 
third their width, and the sides turned in, as shown in Fig. 42, so as 
completely to cover the adhesive surface of that portion. The sides 
of the remaining portion are obliquely notched at several points. A 
piece of wood, 5X3 inches, with a central hole, is then covered with 
adhesive plaster folded beyond the ends, as shown in Fig. 42. 

A third piece of adhesive plaster a yard long ami 2 inches wide is 

cut in two and the halves fastened together end to end by facing their 

terminal four or rive inches; it is attached to the hack oi' the calf, and 

brought along and well beyond the sole o\' the toot ; a roller-bandage 

7 



98 



FRACTURES. 



is applied to the foot and lower third of the leg, the first two strips 
of plaster placed one on each side above it so that their folded por- 
tions extend below the ankle, and the roller carried over them. Unless 
the fracture is too low the roller and strips of plaster should be car- 
ried well above the knee. The ends of the plaster on the wooden 
"spreader" are then attached by pins or clamps to the free ends of the 
lateral plasters so that the " spreader " lies squarely across the sole 
a few inches below it. A cord is then passed through the hole in the 
" spreader " and secured by a knot. 

A Yolkmann's slicling-rest (Fig. 43) is then placed under the leg, 
the foot lightly swung from it by carrying the free end of the third 

Fig. 43. 




Volkmann's slicling-rest for fractures of the thigh. 

strip of plaster over its top and sticking it to its lower surface, and the 
leg secured to it by a roller. This cord is then carried over a pulley 
at the foot of the bed, and a weight of from ten to twenty pounds 
attached. Counter-extension is made by raising the foot of the bed 
about four inches. Coaptation splints about a foot long are bound 
about the thigh to give lateral support, or a molded plaster gutter is 
used, covering the posterior half of the thigh from the gluteal fold to 
the knee. 

Steinmann 1 makes traction by attaching the weight to two nails driven 
into the condyles of the femur, one on each side. Wilniis 2 after having 

1 Steinmann: Ztlblatt, fur Chir., 1907, p. 938. 

2 Wilms : Deutsche Zeitschrift, iiir Chir. Vol. 92, p. 260. 



TREATMENT. 



99 



attached twenty-five kilos during the first week and fifteen during the 
second, in this way found he had lengthened the limb more than an inch. 
This shows that heavier weights can be used in this way than by ad- 
hesive plaster, but it does not seem probable that the method will 
become popular. Wilmis 1 has recently employed this method in five 
fractures of the leg and three of the forearm. Becker 2 used in two cases 
a steel drill passed through the upper part of the condyles, from side to 
side ; he preferred this to nails, as less likely to split the bone or to 
work loose. 



Fig. 44. 




Hodgen's suspended splint. 

Hodgen's suspended splint (Fig. 44) is a modification which gives 
more freedom of motion and consequently more comfort to the patient. 
It consists of two parallel iron bars, slightly bent at the point corre- 
sponding to the knee and connected at the lower end by a straight bar 
and at the upper end by a curved one. The leg and thigh are placed 
between these bars and suspended from them by half a dozen bands, 
and the ends of the lateral pieces of plaster are attached to the lower 
cross-bar, care being taken that they do not press against the malleoli, 
or by the cord of the spreader of Buck's extension. Then the limb is 
raised from the bed by a cord, as shown in the figure, which should be 
attached to a support at least four feet (better more) above the bed and 
so placed that the cord is inclined fifteen to thirty degrees from the 
vertical, and shall thus tend constantly to draw the leg downward : 
this furnishes the traction, and by moving the point of support to the 



i Wilms: Ztlblatt, fur Chir., 1909, p. 79. 
* Becker : Ztlblatt, fur Chir., 1908, p. 1420. 



100 



FRACTURES. 



outer side the position of abduction of the thigh, which is usually 
desirable, can be readily obtained. 

Combined Suspension and Traction (Fig. 45). During the last two years 
I have used a combination of suspension by Hodgen's splint and traction 
by Buck's extension, which has given much satisfaction ; tlie patients 
are much more comfortable than with Buck's alone, and the traction is 

Fig. 45. 








Combined traction and suspension in fracture of the femur. 

more efficient and regular than with the Hodgen. Its application is shown 
in Fig. 45. The Buck's extension is applied in the usual way, and the 
Hodgen splint adjusted with vertical (not oblique) support. The pulley 
over which the Buck's cord passes should be at least twelve or eighteen 
inches distant from the patient's foot so that lateral shifts of his position 
shall not greatly change the line of traction. This can be easily effected, 
when necessary, by so binding the rod which carries the pulley to the 
bed in such a way that the pulley stands well out beyond the foot of 
the bed. Besides the greater comfort of the patient, this has the advan- 
tage of readily giving the flexion and abduction needed in high fractures 
of the femur, and of making coaptation pressure upon the ends of the 
fragments by means of the supporting bands. 



TREATMENT. 



J 01 



The same method of traction is sometimes used in fractures of the 
thigh in connection with a long side splint, either with a weight and 
pulley or with an elastic cord on the side of the splint (Fig. 4<JJ, and 
also with one of the forms of hip-splints. A splint devised by Dr. 
Weed (Fig. 47) uses a steel spring to make traction, and contains many 
ingenious devices to modify the amount of traction and to adapt the 
splint to limbs of different sizes. But in all such the pressure of the 
perineal band is likely to prevent efficient use. 

Vertical suspension, for fractures of the thigh in infants and for some 
fractures of the arm, can be obtained in like manner by the use of the 



Fig. 46. 
Double pulley 




Ind. -rubber accumulator 
Long side splint with traction. 



plaster strips and a cord carried to a point of support directly above 
the bed. (See Chapter XXIII.) 

In the double inclined plane (Fig. 48) traction is made by the weight 
of the upper segment of the thigh and pelvis. It consists of two pos- 
terior splints, for the leg and thigh respectively, hinged at the knee and 

Fig. 47. 




Weed's splint. 



kept at the desired angle by a plank upon which they rest and to which 
the upper end of the short femoral splint is hinged. As shown in the 



Fig 




figure the femoral splint is too long; it musl beso short thai the upper 

part of the thigh is wholly unsupported bv it, and the mattress inu<t 



102 



FRACTURES. 



be so soft that the pelvis can sink into it, for it is by this sinking of 
the pelvis that the upper fragment of the broken thigh is drawn away 
from the lower one. It cannot be depended upon to give a good result 
in respect of shortening, but it is very convenient in some compound 
fractures. 

While efficient traction may usually be confidently depended upon to 
correct not only overriding but also lateral and angular displacements, 
other measures may be needed to correct or prevent these latter or 
rotatory displacement. In the femur outward rotation of the upper 
fragment can be prevented by a sandbag placed behind the great 
trochanter, and lateral or angular displacement opposed by correspond- 
ing lateral traction, made either by the upper supporting bands in a 
suspending apparatus, or by a separate weight and pulley acting trans- 
versely. The latter device has long been employed and recommended 



Fig. 49. 




Bardenheuer's lateral and longitudinal traction. 



by Bardenheuer not only in fractures of the femur but also in those of 
other limbs and even the fingers, and has been developed by him 
to an extreme complexity. 

Constant care and watchfulness are needed to detect and correct dis- 
placements that may arise in the course of treatment through the action 
of various forces, notably gravity, and it is only by such watchfulness 
that grievous disappointment can be avoided. 

Zuppinger has devised splints for making traction by the weight of 
the limb in fracture of the leg and of the thigh, with the knee and hip 
flexed, which have been favorably noticed in Germany and Switzerland. 
While the device seems to be efficient in fracture of the leg, in that of 
the thigh it seems to me to be essentially identical in action with the 
double inclined plane, and both seem to require more constant attention 



TREATMENT. 103 

and ready apprehension of meehanical conditions than can be expected 
in general. I think suspension of the leg with the knee similarly 
flexed would more easily and surely give the desired mechanical con- 
ditions in fracture of the thigh. The splints are described in detail in 
an article by Montandon in the Archives de Chirurgie, 1908, p. 103. 

Direct Fixation of the Fragments. 

This can be effected in a variety of ways, the types being the suture, 
ligature, pin, and central or external brace. Even the plan of baring 
the ends and engaging them in a ferrule of bone has been employed 
in a few cases. It is rarely resorted to except in compound fractures, 
some special ones such as fractures of the patella, and in operations 
after failure of union. 

In determining the advisability of resort to it in any case or in mak- 
ing choice of a method, consideration should be given to the following 
facts : The cases of fracture of the shaft of a long bone in which suf- 
ficient reduction cannot be maintained by a suitable external dressing 
are very rare. The cases are more frequent in which it cannot be com- 
pletely made, or in which it cannot be certainly maintained during the 
application of the dressing. To make complete reduction exposure of 
the seat of fracture may be necessary, and in some fractures thus 
exposed and in some compound ones temporary direct fixation of the 
fragments may be advisable. In fractures of articular extremities the 
difficulty is in making reduction (or in being certain that it has been 
made) rather than in maintaining it, the exceptions being cases of 
extensive splintering. In fracture of apophyses to which powerful 
muscles are attached, such as the olecranon, the coracoid process, the 
greater tuberosity of the humerus, the tuberosity of the os calcis, it 
may be impracticable to maintain a position of the limb in which the 
muscle is so fully relaxed that it will not renew the displacement even 
if it can be corrected, and in such the proper relations of the fragments 
can be secured only by direct fixation ; but in most of such cases the 
continuity is maintained by periosteal or fascial attachments which 
ensure a union, bony or fibrous, sufficient for satisfactory function. 

Another fact, to which I think far too little attention has been given, 
but of which I have been convinced by many observations, is that the 
presence of a foreign body, even if sterile and unconnected with sup- 
puration, in bone at or near the line of fracture notably exaggerates 
and prolongs the preliminary rarefaction of the bone. I believe this 
influence may even cause failure of union by transformation of a con- 
siderable portion of the bone into fibrous tissue, for in several eases in 
which I have operated for failure of union several weeks or months 
after a wire suture has been applied to the fracture I have found the 
suture lying free, and the ends of the fragments thinned and pointed 
and separated by a considerable intermediate mass of fibrous tissue. 
That the holes pierced for such sutures enlarge, and that the bone 
included in the loop wholly disappears is a common observation, ami 1 
believe the same change is promoted for a considerable distance round 



104 FRACTURES. 

about, and although this ill effect is uot to be expected always to fol- 
low, yet its possibility should be seriously considered. 1 

In my judgment, direct fixation by suture or pins should therefore 
be only temporary, with the view merely of holding the fragments 
together during the application of a dressing and for a few days there- 
after, and that the loop of a suture should include only a small portion 
of the cortical layer. Possibly silk and silkworm-gut are less injurious 
than wire, although I have known both wholly to free themselves in 
the same manner as wire, and I am not willing to advise against their 
use as absolutely as I do against that of wire, but I believe that with 
care in handling strong catgut will give all we ought to seek to obtain 
from a suture. 

Temporary fastening by nails or pins is applicable mainly to spongy 
portions of bone ; it has been suggested for fractures of the shaft in the 
form of a long pin passed through the pieces, which are further secured 
by a thread thrown several times over the point and the shaft ; by with- 
drawing the pin the thread is freed. In ParkhilPs clamp one or two 
pins are passed through the skin into each fragment near the fracture 
and held together by a plate. An objection to pins reaching to the 
exterior is the difficulty of keeping their track aseptic ; the objection 
is, of course, greater when the pin passes to the fracture. 

The exteut to which sublime confidence in the innocuousness of the 
knife may lead is indicated in the proposal of Xiehans 2 to treat supra- 
condyloid fracture of the lower end of the humerus by sawing through 
the olecranon, stripping off all the extensor muscles, and nailing the 
fragments together. 

A ligature thrown circularly, or better obliquely in notches, about 
the bone has been employed. 

Fixation by a bone pin inserted lengthwise into the medullary canal, 
by an external metal plate screwed to the two fragments, or by pinning 
or screwing the notched and fitted fragments together has been prac- 
tised, but mainly, I think, in operations after failure of union. 

In fracture of the patella, in which a special indication for fixation 
exists, ample support can be given by catgut sutures in the fibro- 
periosteal covering of the front of the bone and in the lateral expansions 
close beside the bone, or even by a long mediate suture crossing the 
front of the bone and embracing the tendou above and the ligamentum 
patellae below. The exposure and handling necessary for drilling the 
bone are thus avoided, with consequent diminution of risk. Somewhat 
similar methods can be used in fracture of the olecranon when the indi- 
cation exists. 

1 Mumford (Boston Medical and Surgical Journal, May 10, 1894), in a report on 300 
cases of compound fracture, noted that in twenty-seven primary wiring of the fragment 
was done, and that in seven of these necrosis followed. 

v. Brunu (Beilage zum Ztlblatt fur Chir., 1906, p. 123) examined 12 cases of fracture 
of the patella treated by wiring. There was bony union in only 3 ; one silver loop was 
still in place, one had been freed by absorption of the enclosed bone, all the others had 
broken into two or more pieces, and in 3 cases pieces of the wire were found free in the 
cavity of the joint, causing constant discomfort. 

2 Niehans : Arch, fur klin. Chir., vol. lxxiii., part i. 



TREATMENT. 105 

To sum it up, direct fixation is very rarely necessary ; when it i.s 
made convenient by an existing wound it should be temporary, by the 
use either of an absorbable suture or of one that can be easily removed 
after a few days. Pins reaching to the exterior are also objectionable 
because of the difficulty of keeping their track aseptic ; the infection 
may spread to the fracture. 

Massage. 

Massage has shown itself after fracture, as after other injuries, so 
efficient to overcome the early and later swellings, stiffness of contigu- 
ous joints, and dryness and coldness of the surface, the conditions which 
delay convalescence and apparently prolong the period of repair, that 
a somewhat exaggerated impression of its value has found expression 
in some quarters, and it has even been proposed as a sole method of 
treatment to the exclusion of all retentive dressings. To these exces- 
sive claims has succeeded a calmer and more judicial appreciation of 
its merits and limitations, largely through the experience and writings 
of Lucas-Championniere. 1 It appears to be beyond question that by its 
systematic and skilful use in suitable cases the primary swelling is 
lessened and disappears more promptly, the circulation and skin more 
rapidly regain their normal condition, the atrophy of the muscles is 
less and more promptly disappears, and the joints more quickly lose 
their sensitiveness and regain the range of motion which is possible 
under the changed skeletal conditions ; possibly that range after frac- 
ture at or near a joint may be increased by massage over what it would 
be without it, but if so the fact can hardly be demonstrable. 

The claim that repair of the fracture takes place more promptly has 
not, I think, been substantiated and seems to me, moreover, possibly 
inconsistent with certain observations which indicate that repair may 
be delayed by insufficiency of reaction. 

Whether these gains, which amount to a little more than a shortening 
of the period of after-affects, are worth the trouble and expense of 
obtaining them is an economic rather than a surgical question, and it 
is clear that they should be sought for only when there is no danger of 
making greater losses thereby — that is, in cases in which the tendency 
to displacement is slight and can be satisfactorily guarded against. 
This is the case with many fractures at the ankle, wrist and elbow, and 
of the fibula alone ; and in some of the leg, forearm, and arm protected 
by moulded splints one splint will give sufficient protection while mas- 
sage is made after removal of the other. 

Massage is made by light rubbing toward the trunk with the fingers 
and then the whole hand, first beside the fracture and then, as tolerance 
is established, over it. The sittings should last for twenty or thirty 
minutes and be repeated daily. It has seemed to me that the repeated 
application of the elastic bandage was equally advantageous. 

1 Lucas-Championniere : Du massage dans le traitement des fractures, Paris, 1S95. 



106 FRACTURES. 

Ambulatory Treatment. 1 

The suggestions made a few years ago by an instrument maker in 
Germany that in fractures of the lower extremity splints should be 
used which would enable the patient to walk during treatment has led 
to considerable experimentation, the ultimate result of which seems 
likely to be of some benefit to the patient, although far less than is 
claimed by some who have sought to generalize the method. In esti- 
mating the value of the suggestion and determining the extent to which 
the previous use of the method can be broadened, we must discriminate 
sharply between the different forms of fracture. A man with a frac- 
ture of the fibula, of the external malleolus, even with a Pott's fracture, 
can often walk with comparative ease and security under the protection 
of a plaster-of-Paris dressing which limits the motion of the ankle- 
joint and prevents lateral strain upon it. And so too with fracture of 
the patella. To that extent there is nothing new in the idea, so far at 
least as the freedom from confinement is concerned. The claim now 
is that the method can be extended to fracture of both bones of the 
leg and even of the femur, that the loss of time and earning capacity 
is thereby lessened, that union takes place more rapidly, and that the 
joints more promptly regain their freedom of motion and the whole 
limb its normal condition. The comparison in respect of the last three 
points is one that is notoriously difficult to make with accuracy, and it 
has not been helped by the statistics that have been published, for they 
have included a large proportion of the slighter cases, and I think it 
must still be held that the claim has not been substantiated. As for 
the pecuniary value of ambulation on the splint, the advantage seems 
to me to be illusory ; the splint is in that respect no better than a 
crutch, and although it may perhaps be at times more convenient it is 
at others less so. 

On the other hand, the method exposes to risks of displacement and 
of healing with deformity which, in my judgment, outweigh even the 
claimed advantages, and the statistics show that the risk is a real one 
and that damage results in a considerable proportion of cases. 

The principle of construction of an ambulatory splint for a fracture 
of the leg is to make it of plaster of Paris in a way to combine reten- 
tion in the ordinary manner with a support on each side which extends 
well below the sole and takes the weight of the body through its attach- 
ment to the splint well above the fracture, the lower segment of the 
limb hanging between these supports and receiving none of the weight. 
For a fracture of the thigh the dressing is a combination of a fixed 
dressing and a hip-splint which receives the weight of the body at the 
pelvis. 

It is admitted,, I think, by all supporters of the method that it 
should not be employed until after the primary swelling has subsided 
and the early hardening of the soft parts about the fracture has 
appeared, say after a fortnight in a fracture of both bones of the leg. 

1 For a thorough presentation of the history and claims of the method, see Guitard. 
De la methode ambulatoire dans les traumatismes osseux du membre inferieur, Paris, 
1903. 



TREATMENT. 



107 



The limb is then covered with a plaster dressing applied directly over 
the skin except along the sole, where it is separated from it by a layer 
of cotton about two inches thick. Along the sole and on the sides of 
the limb the dressing is made very thick and strong and is sometimes 
reinforced by lateral strips of wood or metal. The other foot must be 
correspondingly raised by a thick sole. It is beyond question that if 
the method is employed the patient should be kept under observation 
and the same precautions as regards removal for inspection should be 
taken as have been shown to be necessary with other splints. 

A safer plan, if it is essential that the patient should walk, is to use 
an ordinary hip-splint for ambulation, the broken leg being separately 
encased in plaster. The same plan can be employed in the later stages 
of fracture of the femur. 

I have found that patients can sometimes walk about with the aid 
of two lateral strips of wood placed outside of an ordinary plaster 
dressing after it has hardened and supported by a shoulder or collar of 
plaster at its upper part, or by a light apparatus of two iron side-pieces 
fastened over a plaster dressing with straps and buckles. 

Management of the Joints. 

The joints in the formation of which the broken bone takes part, 
and often more distant ones, become stiff and sensitive during the 

Fig. 50. 




Bony anchylosis after snpracondyloid fractnre. 



a longer or shorter time thereafter. 

and may become permanent in the 

has involved the joint or when the 

and in the joints of the hand even 

ic causes are varied and 

.llv unavoidable, and sometimes irremovable. The more 



period of repair and remain so for 
This disability is specially marked i 
old and rheumatic when the fracture 
joint lias been eoincidently sprained, 
when the fracture is of the arm or forearm. 



108 FRACTURES. 

important and permanent are those arising from change in the shape of 
the articular end of the bone by uncorrected displacement of a fragment 
or by excessive formation of callus, or by anchylosis, and, in less de- 
gree, from thickeuing and retraction of the periarticular tissues and the 
formation of adhesions within the joint following its sprain or its share 
in the fracture. These are all the result of the primary injury and 
of the inflammatory reaction, overgrowth of callus being most com- 
mon in the young because of the activity of the periosteum in bone 
formation at that period. Anything which diminishes that reaction 
and shortens its duration will, therefore, tend to diminish these ham- 
pering consequences ; anything which augments it will add to them. 
This gives us a standard by which to measure the value and appropri- 
ateness of any method of treatment. Eest, massage, elastic compres- 
sion have long since proved their value to reduce inflammation in 
joints and to remove exudates from within them and from the peri- 
articular tissues; and moderate use, active or passive, to increase the 
range of motion after the inflammatory reaction has ceased. The 
importance, and especially the respective timeliness, of these two 
opposing methods need to be fully grasped. The surgeon's dread of 
anchylosis, his anchylophobia, as it has been termed, too often leads 
him to move and even to force a joint while such motion will still be 
painful and will be followed by an increase in the reaction and a reduc- 
tion of the range of motion, and, on the other hand, if he has well 
grasped the corresponding principle he is in danger of unduly prolong- 
ing confinement and thereby postponing and perhaps restricting the 
restoration of function. The criterion is a plain one : so long as the 
joint is swollen and hot, so long as its use is followed by an increase of 
swelling and heat and by persistent pain, so long must it be kept at 
rest and so long must active treatment be limited to massage or elastic 
compression ; and, as a rule, this attitude of non-interference may be 
maintained without harm until after union of the fracture has become 
complete. Then he may resort to passive motion or may encourage the 
patient to gradually increasing use of the limb, and he will see the stiff 
joint rapidly regain its functions. 

Forcible passive motion, with or without anaesthesia, is always harm- 
ful before the second month, and even after that time it is far more 
likely to do harm than good. About the only condition in which it 
can really help is that of isolated cord-like adhesions within the joint 
which can thus be broken without the probability of their reunion. 
Such a condition we have every reason to believe to be very rare. 
When the method is employed to increase a range of motion that has 
been restricted by the common causes, such as broad adhesions, retrac- 
tion of the capsule with periarticular thickening, and bony irregulari- 
ties, it accomplishes its object only by creating lacerations which 
necessitate immediate immobilization in order to check inflammatory 
reaction and which in healing re-create the original or similar conditions 
and even increase them. The procedure should, I think, be almost 
wholly abandoned, and in its place we should resort to massage, con- 
stant use within existing limits, and possibly to the recently intro- 
duced method of prolonged exposure to high dry temperatures, and 



TREATMENT. 109 

these failing, I should prefer to expose the joint by incision in order to 
remove such intra-articular obstacles as might exist and be removable 
rather than blindly to seek to break and tear them without knowing 
what and where they are. Yet it must be added that occasionally 
joints at a distance from the injury may become so stiff and sensitive 
that the patient can make no progress in freeing them by use of the 
limb, but if once moved freely under ansesthesia they retain the mo- 
bility and lose the sensitiveness. At the ankle particularly such for- 
cible correction of the position of the foot will enable the patient to 
stand upon it and thus begin the gentle use which is needed. 

This general rule of immobilization needs one important addition 
with respect to the fingers. In the treatment of all fractures of the 
arm and forearm the fingers and thumb should be left free and the 
patient should be enjoined constantly to move them ; in addition, if 
the dressing must include a portion of the hand it should be so arranged 
that the wrist will be in slight dorsal flexion, the fingers flexed but free 
to be extended, and the thumb abducted, because these attitudes tend 
to retard and diminish the ill effects of confinement and lack of use. 
If the fingers must be confined it should be in flexion. 

COMPOUND FRACTURES. 

The points here to be considered are those connected with the man- 
agement of the wound of the soft parts and the modifications imposed 
by its presence and character upon the details of reduction and reten- 
tion of the fracture. 

A very important difference is that between fractures by direct and 
fractures by indirect violence, because in the former the wound is 
usually large and so contused .that its prompt uncomplicated healing 
cannot be expected, while in the latter it is usually made from within 
outward by the sharp end of a fragment, is small and clean, and may 
confidently be expected to heal within a few days under proper care, 
thus transforming the fracture into a simple one and putting an end to 
the special dangers which make the injury so redoubtable. Moreover, 
in the former, especially when the muscles as well as the skin are lacer- 
ated, the more virulent streptococcus and even the B. aerogenes infec- 
tions develop with exceptional frequency. I have long noted this 
fact, the frequent development of these redoubtable infections amid 
bruised, torn muscles, when slighter contemporaneous wounds received 
under similar personal conditions and apparently exposed to the same 
contaminations ran an uneventful course. It is unreasonable to assume 
that contamination is limited to the severe cases ; it must occur also in 
some, perhaps in many, of the others. The reason of its development 
in one and not in another must then be sought in the differing condi- 
tions, and I think it may be found in the lowered vitality of the bruised 
muscles, in the products of their changed metabolism, or in their low- 
ered power of resistance. 

These two varieties differ so greatly in prognosis and treatment that 
I shall seek to emphasize the distinction between them by a separate 
description, although it must be admitted that the special difficulties and 



110 FRACTURES. 

dangers which characterize those by direct violence may also exist in 
those by indirect violence in consequence of unusual associated condi- 
tions more or less independent of the mode of production. The essen- 
tial difference is in the condition of the wounded tissue : in the one, a 
lacerated contused wound, some of the skin about which, even if appar- 
ently uninjured, is almost certain to slough ; in the other, a small 
clean wound almost as fit to heal as if it had been made on the operat- 
ing table. 

Compound Fracture by Indirect Violence, or with a Small, 

Clean Wound. 

The patient is anaesthetized and the skin about the wound is cleaned 
as for an operation. If the point of a fragment projects through the 
skin and is rather tightly grasped by it the wound must be freely 
enlarged, and it and the bone irrigated with an antiseptic solution, 
such as the 1-1000 bichloride; reduction is then made, the limb 
pressed to force out the escaped blood, the wound closed with inter- 
rupted sutures at half-inch intervals, and a sterile or antiseptic dress- 
ing applied, with temporary splints. Exceptionally it may be advis- 
able to insert a drain of gauze or rubber, or to explore the wound to 
aid the reduction or to remove fragments, or to secure a torn vessel, 
but the less the wound is handled the better, because of the risk of 
contamination by the fingers. 

About a week later the dressing is removed and if all has gone 
well the fracture is thenceforth treated as a simple one; but if infec- 
tion has occurred the measures described in the next section must be 
employed. 

Compound Fracture by Direct Violence, or with a Contused or 

Infected Wound. 

The patient is anaesthetized, the skin cleaned, and the wound thor- 
oughly Avashed out with an antiseptic solution; loose fragments are 
removed, the ends of the bones regularized if necessary, and the deeper 
layers of muscle and fascia fastened together by sutures so as to give 
support to the fragments; if deemed necessary a catgut or temporary 
suture may be placed in the bone to hold the fragments together. 
Then the enveloping fascia is sutured at a few points, not too closely, 
and the skin sutured so far as its condition permits. Drains of rubber 
or gauze are inserted, and a dressing placed over all. The limb is 
then placed in splints that will permit a change of dressing with the 
least disturbance of the fragments; for the leg Volkmann's splint is 
convenient, or the plaster stocking (page 94), or moulded anterior 
and posterior splints, one of which is placed if possible next the skin 
and protected by rubber tissue or Croux's paste (p. 96) from soaking by 
the discharge (Fig. 51). Later in the course, if the case does well, an 
interrupted or fenestrated splint may be used, but the dressing occu- 
pying the fenestra or interval must be bound on very snugly or the 
tissues under it will become oedematous and project through the open- 



TREATMENT. Ill 

ing. Suspension adds to the comfort of the patient and often to the 
convenience of the surgeon. 

For the thigh Hodgen's splint is usually the most convenient, but 
the double inclined plane is sometimes better. For the arm, especially 
in fractures near the elbow, I like vertical suspension ; it seems to 

Fig. 51. 




Compound fracture. Dressing and plaster splint. 

keep down the reaction very efficiently, but moulded splints are very 
convenient, as they also are for the forearm. 

The condition of the skin about the wound in these fractures 
demands close inspection, for it is usually much more seriously and 
extensively affected than its appearance indicates. It is almost inva- 
riably stripped up from the underlying parts for a considerable dis- 
tance and certain to slough, often over a large area, although it may 
show no sign of the injury received. (See page 67.) 

I have experimented somewhat on the possible advisability of cut- 
ting away at once all skin that is clearly certain to slough in order to 
diminish infection and favor drainage from beneath it, but have not 
been able to satisfy myself that it is best to do so. If the infection is 
slight the skin mummifies and but little exudate forms under it, and it 
serves, by the sutures placed in it, to prevent retraction of the adjoin- 
ing portions ; it can be cut away later, in the second or third week. If, 
on the other hand, the case does less well the dying or dead skin can be 
removed at the second or third dressing with, I think, no serious loss 
from the attempt to utilize and save it. Extensively crushed and lac- 
erated subcutaneous tissue can be satisfactorily treated with balsam of 
Peru. 

Lacerated and divided muscles should be adjusted as nearly as possi- 
ble in their normal relations and may be secured there by a few catgut 
sutures, but the main reliance upon their proper reunion is in the closing 
of the enveloping fascia over them, with intervals for drainage. Divided 
nerves and tendons are, of course, to be sutured, and torn vessels tied. 

The proper management of fragments of bone is often a matter of 
anxious doubt and the surgeon must be guided somewhat by the prob- 
ability of avoiding extensive suppuration, for fragments may safely be 
left in wounds that are to heal kindly which must certainly be removed 
sooner or later if suppuration takes place about them. It has been 
abundantly demonstrated that even wholly detached fragments can 
maintain or regain their vitality and be an important aid in establish- 
ing union between the main fragments if infection is avoided. It* the 



112 FRACTURES. 

loss of bone is considerable it is advisable to square the ends of the 
main fragments and bring them close together ; in the leg this loss is 
usually at the expense of the tibia, and the fibula must then be corre- 
spondingly shortened. 

If the laceration of the muscles is great, and persistent infection 
probable, abundant provision for drainage and irrigation should be 
made. Long fenestrated rubber tubes should be run through the limb, 
by counter-openings, and should project through the dressings so that 
an antiseptic solution can be frequently injected during the first few 
days or until the infection is under control. If suppuration becomes 
fully established it must be treated according to general principles, or 
amputation must be done. 

Gunshot Fractures. 

Gunshot fractures, when the missile is small, can generally be suc- 
cessfully treated by a single irrigation of the wound and an antiseptic 
dressing without removal of the bullet. It is very rare for a piece of 
the clothing to be carried in beyond the skin. When the missile 
is a large rifle ball or a charge of shot at close range the destruc- 
tion of the soft parts is such that prompt closure of the wound can- 
not be expected, and the case must be treated as one of the second 
class just described. I have recently, 1898, seen two cases of frac- 
ture of the upper end of the femur, one of the carpus and radius, 
and one of the humerus, by Mauser balls, which healed without sup- 
puration. 

Amputation. 

There is a class of cases, fortunately not a large one, in which pri- 
mary amputation is clearly indicated, cases in which the fracture is 
only one, and sometimes not the most important, of the injuries 
received. The extensive destruction of the soft parts, sometimes also 
of the bone, makes it evident that the limb cannot be saved or that if 
saved it would be useless. The only question is as to the time and 
place of amputation. I am confident that in some of these cases a 
formal amputation well above the injury should be rejected in favor of 
division of the remaining soft parts at the upper limit of the laceration 
and the removal of only so much of the upper fragment as can be 
conveniently reached from the surface of section. These are the cases 
in which the soft parts have not been torn and bruised above the line 
of their division, and in which it is important to save as much as pos- 
sible of the length of the limb, or in which a formal amputation would 
sacrifice a contiguous joint, especially the knee or elbow. Recovery of 
course would be slower, but under the protection of asepsis the stump 
would be more serviceable than those which were formerly obtained 
after suppuration and whose defects led to the rule of practice which 
now, I think, needs revision. Such limited experience as I have gained 
in the matter encourages me to invite consideration of it. 

Doubt as to the advisability of amputation and anxiety as to the 
result if amputation is not done arise in those cases in which the injury 
is not clearly destructive of the limb or its usefulness, but in which 



TBEA TMENT. 1 1 3 

the attempt to save it will imperil life by the progress of an infection 
already present or certain to result from the sloughing of the bruised 
tissues. It is a peculiarly anxious question for the surgeon, for it 
involves his reputation' for sound judgment as well as the welfare of 
the patient. Weighing the probabilities he may wisely decide that the 
chance of saving the limb or of its usefulness if saved is not such as 
to justify the taking of the risks involved in the attempt to save it, and 
yet if the patient refuses amputation and happily saves both life and 
limb the advice to amputate is likely often to be recalled as a reproach 
or an error of judgment. In some cases it is probable that under the 
protection of antiseptics the decision can be delayed until time shall 
have shown the full extent of the injury and the ability or inability 
to control the infection, with a reasonable expectation that a later am- 
putation, if necessary, will still be in time to save life ; but in other 
cases, particularly in the middle-aged and alcoholic and in those with 
diseased organs and tissues, the infection is so superior to the organ- 
ism's power of resistance that if it is allowed to become fairly estab- 
lished death is inevitable. In the first set of cases the surgeon may 
fairly place the responsibility of delay, of taking the chances, upon the 
patient or his friends ; in the latter he must throw the whole weight of 
his opinion unreservedly in favor of immediate amputation unless he 
is forced to believe that even that will be unavailing. An infection in 
a middle-aged patient which in a few hours has produced a condition 
of apathy or subdelirium, with brownish discoloration of the skin 
extending rapidly upward and a dark offensive discharge ' from the 
wound, cannot be arrested by amputation, except perhaps when it has 
not got above the knee or elbow ; but one which is marked rather by 
abundant suppuration, even with high fever, by less implication of the 
sensorium, and by a slower, reddish, boggy oedema of the parts about 
and above the wound can often be saved by amputation. 

An interesting analysis of one hundred and thirty-seven cases of 
compound fractures of long bones has been made by Klauber. 1 Ninety 
were by direct, forty-seven by indirect violence. Twenty-four are 
classed as traumatic amputations, primarily operated upon to regularize 
the stump — one death ; fourteen were treated by primary amputation — 
two deaths ; fifteen treated conservatively — three deaths, and two suc- 
cessful secondary amputations ; average length of treatment one hun- 
dred and three days. 

Compound Articular Fracture. 

In these cases also conservative treatment has gained much additional 
ground ; the outlook and details vary, as in fracture of the shaft, with 
the character and extent of the injury to the soft parts. In addition 
to the principles governing the treatment of similar fractures oi the 
shaft the surgeon has also to consider the conditions arising from the 
implication of the joint, especially the probability of the extension 
of suppuration to it and the effect upon its functions oi' such sup- 
puration or of the injury itself. W the wound is small and clean 

1 Klaviber: Beitriige zur klin. Chir., vol. xliii. p. 319, 



114 FRACTURES. 

its communication with the joint may be disregarded, or, at the most, 
drainage of the joint made and maintained for twenty-four to forty- 
eight hours. The principle in any case of moderate or extensive lacera- 
tion and contusion of the soft part, in which the attempt is made to 
preserve all the articular portions of the bone and the functions of the 
joint, is to protect the joint by drainage against the consequences of 
primary infection and against later infection from the wound itself by 
assuring the early escape of the exudates of the latter. In the more 
severe cases — laceration, splintering of the articular end, free commu- 
nication between the wound and joint — drainage may be made directly 
through the wound and even partial excision of the joint may be done 
to insure its thoroughness. 

The probable effect of the injury to destroy the functions of the joint 
raises the question of resection with a view to restrict the loss. The 
answer varies with the joint and to some extent with the vocation of 
the patient, for at some joints and in some occupations solidity is more 
useful than mobility with insufficient control. Thus, at the knee anchy- 
losis is preferable, at the ankle the removal of the astragalus may leave 
a useful limb, but anchylosis is better than removal of the lower portion 
of the tibia, at the elbow a stiff joint in a good position is more useful 
than one that is very loose for a man who has to do heavy work, while 
for one who does light work, using mainly his fingers and wrist, even 
a loose elbow would be better than a stiff one. We have learned too 
that partial resections under the protection of the antiseptic method 
give much better results in respect of mobility than they formerly did ; 
thus, removal of the lower end of the humerus with conservation of 
the olecranon gives usually a more useful joint than total resection 
does. 

GENERAL TREATMENT. 

The vital indications in simple fracture of the limbs rarely arise 
except in the aged and the alcoholic. In the former the shock of the 
injury, frequently a fracture of the neck of the femur, occasionally 
proves fatal within a day or two, or the strength gradually fails and 
the patient dies about the third week, often with symptoms of localized 
pneumonia at the end. Against this there is little that can be done 
except to avoid dressings which give pain and increase discomfort. I 
do not believe that the recumbent posture increases the latter danger 
or can be safely discarded during the first three weeks. At a still 
later period it may sometimes be advisable, because of the general con- 
dition, to take the patient out of bed even at the risk of failure of union. 

In the alcoholic, it is important to maintain nutrition and secure sleep 
during the first week, and to give alcohol regularly in moderate quan- 
tities ; it is claimed that the chance of an alcoholic outbreak — delirium 
tremens — is less if the patient is not kept in bed, and for that reason 
an early application of a fixed dressing is advised. 

No medication, except tonics, appears to have any value in hastening 
or assuring union of the fracture except when some specific poisoning 
is present, such as syphilis or paludism, when mercurials and quinine 
are respectively indicated. 



CHAPTEE VIII. 

DELAYED UNION, FAILURE OF UNION, PSEUDARTHROSIS, 

FAULTY UNION. 1 

Delayed Union ; Failure of Union. 

In the use of the terms delayed union, fibrous union, and failure of 
union or pseudarthrosis, a certain vagueness of differentiation is inevi- 
table because of the frequent lack of knowledge of the exact anatomical 
conditions and because the time requisite for the complete repair of 
a fracture varies so much in different cases that it may not be pos- 
sible to say whether in a given case the process has come to a standstill 
or is still slowly but surely continuing. This vagueness, moreover, is 
not simply clinical but extends also to the anatomical condition, for 
in most cases this represents a stage through which the process of 
repair commonly passes, that of union of the fragments by a bond of 
fibrous tissue, and the abnormality consists in the delay or failure of 
that bond to ossify. Furthermore, as this final step, ossification, is 
often still possible after a delay of many months, a case which fully 
deserves, clinically, to be termed " failure of union," one in which 
special measures are required to excite ossification, is yet identical, 
anatomically, with another in which ossification will follow without 
other aid than the prolongation of the usual immobilization. The 
term pseudarthrosis, literally false joint, is not restricted to those rare 
cases in which some of the characteristic anatomical elements of a 
joint are present, but is used as a synonym of failure of union. In 
cases in which bony union is from the first unlooked for, or has been 
deemed unlikely, as in most fractures of the patella without operative 
treatment, the term " fibrous union " is habitually used instead of 
" failure of union/' 

While delay in union is not infrequent, failure of union is rare. 
The published statistics of failure differ so widely that it is evident 
the same basis of classification has not been followed, and probably 
those which give the large proportions include cases of delayed union 
and possibly even fractures of apophyses which are habitually so dis- 
placed by attached muscles that only fibrous union is probable. Fail- 
ure is more frequent, actually and relatively, in the shaft of the humerus 
than in that of any other bone (except perhaps the radius and ulna), 
and in the prime of life than at any other age. It must be remembered 
that these statements and most of what follows relate only to the shafts 
of the long bones, and do not include fractures of the short bones, of' 
apophyses, or even of the neck of the femur. Delayed union is most 
frequent in the leg and arm ; it is much more frequent after compound 

1 For statistics see Norris: American Journal of the Medical Sciences, 1S4'2, vol. 
xxix. Agnew's Surgery, vol. i. Gurlt: die Knochenbriiche. Berenger-Feraud : 
Traite, des fractures non-consolide>s on pseudarthroses, 1871. For experimental 
study : Cornil and Coudray, Revue de Chir., 24th year, No. 7. 

115 



116 FRACTURES. 

than after simple fracture. According to Von Brims' s statistics 
delayed union occurs in about 1\ per cent, of fractures of the shaft of 
the bones of the limbs, and failure of union in about half of 1 per cent. 

Pathology. Although the anatomical conditions differ greatly in 
detail they may be conveniently classified in two groups, one, contain- 
ing most of the cases, in which the fragments are united end to end or 
laterally and more or less closely by fibrous tissue, and another, very 
rare, in which a distinct joint has formed between them. The varie- 
ties of the first form are very numerous, the variations depending upon 
the relative positions of the fragments, the extent of the preliminary 
rarefaction, the amount of fibrous tissue, and the presence or absence 
of a productive osteitis or partial ossification of the bond. In short, 
the process of repair in an}^ of the widely different forms imposed 
upon it by the character of the fracture and the displacement may be 
arrested at any period or may be continued unevenly but still incom- 
pletely at different points. Thus, the fragments may be in close ap- 
position and united by a short firm bond with only slight motion 
between them, or they may overlap in such a way that the surfaces of 
fracture are not apposed and the union is only by the thickened inter- 
posed connective tissue ; or the displaced end may be enlarged, with 
osteophytes extending into the fibrous bond and separate nodules of 
bone developed within it, needing only a slight additional ossification 
for complete bony union ; or the effect of the preliminary rarefaction 
of one or both fragments may not have been corrected by subsequent 
ossification, and they remain soft and spongy, or atrophied and pointed, 
and even this process of rarefaction may be so exaggerated as to create 
as distinct a gap between the fragments as if a piece had been removed 
or even to transform the entire shaft of the bone into a fibrous cord, or, 
as in a case of fracture at the lower end of the humerus reported by 
Machol, 1 to cause the disappearance of the epiphysis. 

Of the second form, the creation of a joint between the fragments, 
only a few examples have been recorded. They show, in more or less 
complete and distorted forms, joints with a fibrous capsule embedding 
cartilaginous or bony nodules, a cavity containing a synovia-like 
liquid, and the ends of the fragments rounded, eburnated, usually 
enlarged, sometimes smooth and polished and sometimes covered with 
a fibrous or even a cartilaginous lining. 

Etiology. Certain general conditions have been deemed a cause of 
delay or failure of union either through a specific poison, as in syphilis, 
or through a deterioration of the health or a lowering of the vitality 
induced by them, as pregnancy, lactation, defective nourishment, and 
acute diseases ; but it is beyond question that the causes are usually 
local and that the most common one is a faulty relation of the frag- 
ments to each other, including therein the interposition between them 
of muscular tissue. Others are defective innervation, disease of the 
bone, inflammation on the surface, and defective treatment, and in 
compound fracture the prolongation of suppuration and the existence 
of parcellary necrosis of the ends of the fragments. But it is also 
true that delay and even failure may occur when no local or general 

i Machol: Centralb. fur Chir., 1904, p. 1399. 



DELAYED, FAILURE, OB FAULTY UNION. 117 

cause can be found, when the fragments are in exact apposition, 
and when the general condition is good. We know that the less the 
primary displacement, the more exact the reposition, and the more 
complete the immobilization, the less is the local reaction and the 
smaller the callus. It is possible, therefore, that the reaction — the 
hyperemia and the exaggeration of the local nutritive processes — may 
be too slight or too brief to complete repair, but this only throws the 
question further back, and we have yet to learn why the reaction is 
insufficient in one case and sufficient in others which are apparently 
identical. In a few compound fractures at the lower end of the leg 
and of the arm in which after a delay of two or three months I have 
exposed the fragments to remove a sequestrum or for readjustment, I 
have noticed that while the upper fragment was richly supplied with 
blood the lower one was pale and the granulations capping it soft and 
scanty. The appearance suggested that the loss of the blood usually 
supplied to the lower fragment by the nutrient artery might sometimes 
leave it too scantily supplied for active reparative work. Injury of 
the nutrient artery may then be one of the causes of delayed union. 
In the leg and in the forearm a condition occasionally exists which is 
not found where there is only a single bone. For example, the fibula 
unites, but the rarefactive process in the tibia is exaggerated and leaves 
the fragments separated by quite an interval occupied by granulations, 
and the ossification which follows is not active enough to extend entirely 
across it. If the bone were single it seems not unreasonable to sup- 
pose that the fragments would be brought nearer together and the 
intermediate granulations stimulated by the pressure caused by the 
contraction of the muscles, but here the fibula holds the fragments 
apart. This exaggerated rarefaction can sometimes be directly observed 
in compound fractures, especially in the spongy tissue near the epiphy- 
ses. The delay commonly observed after resection for the relief of 
pseudarthrosis I attribute to the absence of a periosteal bridge and to 
the stripping back of the periosteum from the cut end of the bone. 

The defective relations of the fragments consist mainly in a dis- 
placement by which the fractured surfaces are more or less widely sep- 
arated and which is maintained perhaps by the interposition of muscle. 
This interposition, which has occasionally been demonstrated by opera- 
tion, is thought by some to be by far the most common cause of failure 
of union, but in the present lack of observations the opinion must be 
deemed too exclusive. It is probable that when interposition occurs it 
is by penetration of the sharp point of one fragment into the overlying 
muscle. Another form of defective relations is constituted by the inter- 
position of a fragment wholly or partially detached or by the loss, in a 
compound fracture, of one or more fragments and the consequent erea- 
tion of a considerable gap. 

Delay or failure in compound fracture is furthered by necrosis o\' 
the end of a fragment. If the sequestrum is large it creates a gap ; it' 
it is small and lodged amid the granulations which arc awaiting ossifi- 



118 FRACTURES. 

cation, it has seemed to me that its action might be similar to that 
which I have attributed to the metallic suture. I have found several 
such small imbedded sequestra amid pale granulations in exposing old, 
long-delayed compound fractures. It seems, too, as if the impulse to a 
productive, ossifying, process was lost or greatly diminished after the 
lapse of the time usually sufficient to repair, and it is well known that 
it can be re-aroused by fresh local violence. 

Failure by defective innervation, as shown by Bognaud, 1 occurs 
when the trophic nerves or nerve centers of the limb are injured. 
Motor or sensory paralysis without injury of the trophic apparatus 
does not delay union. Bognaud collected six cases of failure of union 
of fracture of the leg with paraplegia due to injury of the spinal cord 
at or below the last dorsal vertebra, while in others in which the paral- 
ysis was incomplete or the spine was injured at a higher point union 
took place. 

Local diseases, syphilis, cancer, etc., which by destroying or soften- 
ing the bone lead to " spontaneous " or " pathological " fracture, act 
in like manner to prevent repair ; and deep suppuration in compound 
fracture, which is usually associated with necrosis, is a frequent cause 
of delay or failure. 

The presence of an open wound exposing a fracture, even when sup- 
puration is slight and superficial, I have observed in several cases to 
be accompanied by marked hyperemia and softening of the bone and 
by great delay in union of the fracture even when the fragments were 
in exact apposition. 

Defective treatment includes the failure to correct the displacements 
which make union difficult and which might be corrected, to secure 
immobility and maintain it for a sufficient length of time, and possibly 
certain errors of commission, such as the excessive use of cold upon 
the limb. Of these, frequent movement of the fragments upon each 
other has long been thought to be a potent factor in delaying union, 
but recent experience in treatment by brief immobilization and frequent 
massage suggests a revision of the opinion. 

The return of mobility after union has become apparently complete, 
and even after the patient has used the limb for some time, is occasion- 
ally observed. In most of the cases probably the union has only been 
fibrous, although close and firm, and has slowly yielded under use ; but 
in others, in which there is no reason to doubt the solidity of the union, 
the cause has been a local inflammation, such as erysipelas, or an ulcer, 
an acute febrile disease, or scurvy. 

Symptoms. The persistence of abnormal mobility after a lapse of 
a period that is usually largely sufficient for union constitutes " de- 
layed " union ; the merger into " failure of union " is a matter of 
opinion rather than of exact definition. If the position of the frag- 
ments is good and the mobility slight the condition should be deemed 
merely one of delay for a much longer period than when the local 
relations are less favorable, and the usual treatment of a fracture 
should be continued ; the instances are numerous in which union has 

1 Bognaud : Sur l'influence de quelques lesions du systeme nerveux sur la formation 
du cal, These de Paris, 1878. 



DELAYED, FAILURE, OR FAULTY UNION, 119 

finally become complete after the lapse of several months and without 
exceptional measures. Ou the other hand, failure may be predicated 
even before the usual time has passed if the position of the fragments 
is very unfavorable and the mobility still great. 

The persistence of abnormal mobility is the pathognomonic sign, 
but it is occasionally difficult or even impossible of recognition either 
because it is very slight or because the fracture is so close to the articular 
end of the bone that the mobility is masked by the movements at the 
joint ; under such circumstances the functional disturbance and pain 
may be the only symptoms. The abnormal mobility may be slight or 
very free, and is usually painless until its limits are approached or 
reached. 

Functional disturbances vary with the extent of mobility, the limb, 
and the amount of the associated muscular degeneration ; it ranges 
from complete disability to interference so slight as scarcely to be 
noticeable ; in one of my own cases, a compound fracture, the patient 
preferred amputation of the leg to longer delay, and others have sought 
in amputation relief from the pain of the mobility. Others, again, are 
able to use the limb with the aid of a brace, and some even without it. 
In the shaft of the femur the disability is usually the greatest and is 
practically complete, but when at its neck the limb may be still quite 
useful ; I have seen several such cases. 

Treatment. When delay has occurred and the local conditions are 
such that union may reasonably be hoped for, the surgeon's first duty 
is to seek for and combat any general condition that may be at fault, 
such as syphilitic or malarial poisoning or defective nourishment, using 
the respective remedies and tonics, and perhaps giving preference among 
the latter to phosphorus or phosphate of lime. 1 Then he continues the 
immobilization, aiding it then or a little later by massage ; this still 
failing, he has choice of a number of mild measures to hasten the proc- 
ess, such as the application for a few hours, once or twice repeated, of 
a bandage about the limb above the fracture tight enough to cause 
venous congestion and swelling (Bier), the painting of the skin with 
iodine, or the injection of a few drops of tincture of iodine or of a 10 per 
cent, solution of the chloride of zinc into the periosteum and the fibrous 
bond at the fracture ; or, in the case of the leg, if the mobility is slight 
and the fragment in good position, he applies a splint or brace by the 
aid of which the limb can be used in walking without too much risk 
of causing displacement, in the hope that the irritation thereby pro- 
duced at the fracture may stimulate the process. Bier (3Iecdzinisehe 
Klinik, 1905, No. 1) recommends the hypodermic injection about the 
fracture of 30 c.cm. of blood drawn from a vein of the patient. 

Some interesting experiments with the method are reported by Hil- 
genreiner (Beitrage zur Min. Chir. Vol. 54, p. 581.) Anzilotti (Arch. 
di Orthopedia, 1908, Pt. 1) obtained union by fifteen injections o1i 
gelatine. 

1 Gauthier: Lyon Medical, June and July, 1897, reports the successful use in two 
cases of the thyroid extract to cause consolidation after delay of about three months; 
the remedy was used for between three and four weeks and union was then estab- 
lished. I have employed it in two cases without recognizable benefit. 



120 FRACTURES. 

If these also fail or if the condition calls for more pronounced meas- 
ures, he seeks to produce a sharp reaction by forcibly and widely bend- 
ing the limb at the fracture, under an anaesthetic, so as to tear the bond 
and measurably produce the conditions of a fresh fracture, or he passes 
a drill down to the bone, with or without incision, and perforates the 
ends of the fragments at several points. Bone and ivory pegs have 
been inserted into holes thus made and withdrawn after a few days or 
weeks, but apparently Avith no advantage over simple drilling. 

Electrolysis has also been used with advantage, the needle being 
passed into the bond between the fragments. 

Finally, the surgeon may freely expose the fracture by incision, resect 
the ends of the fragments, bring them into close and exact apposition, 
and secure them there by external dressing with or without the aid of 
a suture or other fastening applied directly to the bone. In the pre- 
ceding chapter, I have given reasons for thinking that the presence 
of a permanent metallic suture or pin interferes with the processes 
by which alone union can be accomplished, and I must repeat my 
belief that sufficient security can be given by an external dressing, 
and that the usefulness of a suture is limited to keeping the fragments 
in position during the application of that dressing. No suture that 
can properly be used is strong enough to relieve the surgeon from the 
necessity of great care in handling the limb during the application of 
the dressing, not because the fragments have a great tendency to slip 
apart laterally, but because the angular deviations which are certain to 
take place bring a great breaking strain upon the suture. For this 
reason I believe that if any suture is used it should be of catgut or 
silk, and tied loosely so as to permit angular deviation within a mod- 
erate range. The best security, I believe, lies in making the ends of 
the bone square and then having an assistant press the lower segment 
of the limb forcibly against the upper one until the dressing has been 
completed. I have successfully operated upon at least six cases of 
failure of union of the femur in this way and without suture. I may 
add that I have seen as many cases of pseudarthrosis of the leg that 
had been unsuccessfully sutured with silver wire, and in all of them I 
have found at the second operation the wire lying loose and sometimes 
broken. (See also Plate XLVL, fig. 2.) 

If on resection the end of the bone is found thickened and dense I 
drill it in several places in order to promote its rarefaction by increas- 
ing the area of irritation, and under such circumstances the use for 
two or three weeks of a silk or other removable suture might further 
the same aim and thereby be advantageous. In the humerus and in 
the bones of the forearm I have used both absorbable and temporary 
silk ligatures. 

A pin of bone or the thigh bone of a fowl has sometimes been in- 
serted into the medullary canal to hold the fragments together; if 
asepsis is preserved it may heal in, but it usually needs to be removed. 
Bardenheuer quotes Lane as having seen sarcoma develop after implan- 
tation of a piece of bone. 

According to Von Brims out of 440 resections for pseudarthrosis 
203 failed. 



DELAYED, FAILURE, OR FAULTY UNION. 121 

When failure of union has been due to loss of bone the gap lias 
sometimes been filled and union obtained by pieces of fresh or decalci- 
fied bone over which the soft parts are closed by primary healing. 
Absolute asepsis is necessary to success. Apparently the pieces act 
only mechanically by furnishing a framework within and around which 
the granulations grow and by filling the space which if left to be filled 
by the slowly forming granulations would collect the exudates and thus 
favor the spread of chance infection. It has also been proposed to fill 
the gap with powdered calcined bone on the theory that it would equally 
well fill the space and serve as a framework, and would also supply the 
lime salts needed for the formation of bone. The plan commends itself 
by its simplicity and cleanliness, for the powder can be perfectly ster- 
ilized by fire, and I have thought it might also be useful in delayed 
compound and even simple fractures, the powder being poured in 
among the granulations or introduced through a hypodermic needle 
mixed with water. 

When loss of substance has occurred in one of two parallel bones, as 
in the leg or forearm, it is usually advisable, if the gap is not too large, 
to excise a corresponding piece from the other bone so that the frag- 
ments of the first can be brought into contact. When the gap has been 
larger in the tibia a solid limb has been obtained by dividing the fibula 
and uniting its lower segment with the upper segment of the tibia. In 
time the bone enlarges sufficiently to make the limb strong and useful. 

Faulty or Vicious Union ; Union with Deformity. 

The use of these terms is restricted to cases in which the deformity 
or persistent displacement differs notably from the result usually 
obtained after that form of fracture ; the term is not applied when the 
irregularity is slight or common. Thus it is not applied to moderate 
shortening by overriding in oblique fractures, to the shortening and out- 
ward rotation commonly seen after fracture of the neck of the femur, 
or to the deformity of the wrist so frequently seen after Colles's fracture. 
In short, its use implies a condition that might and should have been 
avoided. 

Any of the possible displacements after fracture may remain uncor- 
rected and produce this condition, but the most common are marked 
angular displacement or rotation after fracture of the shaft and trans- 
verse displacement with overriding. Excessive size of the callus is 
sometimes included in this group and so is the inclusion in the callus 
of muscle, tendon, or nerve. The ill results are not limited to the 
change in the appearance of the limb, which is often marked and 
offensive, but include also an interference with function, which may 
amount to complete disability by shortening of the limb, by the devia- 
tion of its lower segment, or by restricting the movements of a neigh- 
boring joint either directly or indirectly by implication of its muscles. 
Thus angular displacement, with or without overriding, after fracture 
of the thigh near the middle may produce a shortening of several 
inches; angular displacement after fracture of the leg may so raise the 
heel or toes or invert or evert the foot as to make it difficult or impos- 



122 FRACTURES. 

sible to place the sole squarely on the ground in walking ; transverse 
displacement backward or forward close above the elboAV may limit 
flexion or extension respectively, more, I think, by cicatricial implica- 
tion of the muscle than by contact with the bones of the forearm. 

Treatment. The method of treatment varies with the solidity of 
union, and therefore to some extent with the length of time, that has 
elapsed. As persistent displacement is often a cause of delay of union 
and of early weakness of the callus, it is possible to correct the posi- 
tion by the hands alone at a much later period than under better con- 
ditions ; that is, an angular displacement can thus be corrected by 
forcibly straightening the limb with the hands or with the knee pressed 
against the projecting angle. But little improvement in overriding is 
to be expected from such means because the cicatricial condition of the 
soft parts which maintains it cannot often thus be modified. A few 
cases have been reported in which continuous traction has been quite 
efficient. Gradual straightening has occasionally been effected by a 
lateral brace with transverse elastic pressure at the angle. 

Refracture by specially devised osteoclasts has been much employed 
in the past for the correction of angular deformity, but has largely 
given place of late to open operation. Some of the instruments are 
very powerful and accurate in the application of the force. Union 
after early refracture may be confidently expected to require less time 
than after primary fracture. A serious obstacle to success may exist 
in the permanent retraction of the soft parts on the concave side when 
the deformity has long existed. The condition then resembles that of 
a bent bow, and as the length of the soft parts determines that of the 
limb the latter cannot be increased, and the bone can be straightened 
after breaking it only by forcing the ends of the fragments past each 
other, overriding. 

Osteotomy meets the indications in the same manner as osteoclasis, 
but more widely and precisely, for it not only insures division at the 
chosen point, but it also permits the correction of lateral displacement 
and the removal of a V-shaped or longer piece if the condition is 
that mentioned at the close of the preceding paragraph. With strict 
attention to asepsis recovery is likely to be as uneventful as after 
osteoclasis, but it will be notably slower if bone is excised. Unless 
anatomical reasons to the contrary exist the incision should be made 
longitudinally at or near the most projecting part of the bone, and 
should be long enough to permit free exposure arid easy access to it ; 
the management of the bone will be determined by the relations of 
the fragments and by the end in view, but in case of excision every 
effort should be made to maintain the continuity of the periosteum on 
one side and to restore it by suture on the other at the end of the 
operation. 

In articular fracture with displacement, such as Pott's fracture 
above mentioned, the bone can sometimes be restored to place by open 
operation with considerable improvement in function. I have im- 
proved the condition in a number of Pott's fractures in this way ; and 
in one of accidental refracture of the outer condyle of the humerus 



DELAYED, E ALLURE, OR FAULTY UNION. 123 

in which the primary fracture (two years previous) had resulted in 
considerable limitation of motion, I exposed the fracture by incision 
because of non-reducible displacement of the fragment, and was able 
so to place it that the range of motion was subsequently increased. 
Possibly a like advantage could be gained by a deliberate osteotomy 
and shifting of the fragments. 

An excessive portion of callus or a projecting fragment which causes 
pain or ulceration of the skin by pressure can be removed by the chisel 
or rongeur. 



CHAPTER IX. 

GENERAL PROGNOSIS. 

The prognosis after fracture involves consideration of the effects of 
the injury in respect of the prolongation of life, the preservation of the 
limb, its usefulness if preserved, and the time required for recovery. 
The factors in the prognosis have been considered in detail in the pre- 
ceding chapters and will only be grouped here for a more convenient 
general review. 

The prognosis varies with the age and condition of the patient, the 
position and character of the fracture, and the complications present or 
possible. 

The Patient. Sex does not affect the prognosis. Age has a con- 
siderable influence ; the younger the patient the better the prognosis, 
because in the young fractures unite more easily and promptly than 
in the adult, and advancing years increase the probability of dimin- 
ished vitality and of the presence of constitutional dyscrasise. In the 
old the prognosis is worse in respect of life because of their diminished 
ability to withstand the shock and to bear prolonged confinement to 
bed and pain, and worst in respect of function because of the greater 
difficulty with which the affected soft parts and joints regain their 
original conditions. The reduction of vitality by degeneration or dis- 
ease of various organs may have a similar effect. Chronic alcoholism 
exposes to an outbreak of delirium tremens and, as does also advanced 
age, to the so-called hypostatic pneumonias. 

Sudden death by fat or pulmonary embolism is possible, but very 
rare, at any age and with almost any form of fracture. 

The Fracture. In compound fracture the prognosis is worse in every 
respect than in simple fracture, and worse when by direct violence than 
by indirect violence because of the usually greater extent and severity 
of the associated lesions of the soft parts. 

The fracture of the shaft of a long bone generally heals with some 
shortening, the chief exceptions being the incomplete and subperiosteal 
fractures of the young and transverse fractures in which lateral and 
angular displacements can be reduced or prevented. 

Fractures of the short or spongy bones heal promptly, but the dis- 
placement, with or without crushing, cannot usually be fully corrected. 
Fracture of the spongy end of a long bone usually heals more quickly 
than fracture of the shaft, but occasionally delay, or even failure of 
union, is occasioned by exaggeration of the preliminary rarefactive 
process. Fracture of a flat bone is rather frequently followed by 
exaggerated formation of callus. 

Fracture of one of two parallel and connected bones (leg, forearm) 
is more easily managed and has a better prognosis than fracture of both 

124 



GENERAL PROGNOSIS. 125 

or of a single bone, because the unbroken one acts as a splint ; an 
exception to this is found when the fracture is accompanied by a loss 
of substance which creates a gap between the fragments. 

Articular fractures and fractures near the joints are especially liable 
to be followed by limitation of motion in the joint; at the knee and 
elbow, and to a less extent the shoulder and hip, this is the rule. 

No general statement of value can be made as to the time required 
to reach the final result after fracture or as to the completeness of resto- 
ration of function, and the statistics that have been collected are prac- 
tically valueless because they do not completely discriminate between 
the different forms and ages of the patients. Each fracture or at least 
each class of fracture must be judged by itself, and in many a given 
case there can be no great certainty that it will not vary widely from 
the average. As I write this paragraph, I have just visited a patient 
who broke the outer portion of the head of the tibia seven months ago ; 
I predicted great loss of motion and was gratified when at the end of 
about four months a range of 45° had been obtained, and yet within 
the last two months that range has been increased to 90° under natural 
use of the limb. I think it can properly be said that an uncompli- 
cated fracture of the shaft of the long bone of the arm, forearm, or 
leg will, in the great majority of cases, heal without any diminution of 
the earning capacity of the patient after six months, and that almost 
all the remainder will have reached the same condition in a year. In 
fractures of the shaft of the femur more time is required, and the 
number of those who will remain more or less disabled is greater. As 
middle life is passed, the ability of the patient to adapt himself to 
changed conditions is less, the joints are more likely to be stiffened, 
and pain in the limb after fatigue or when the weather is cold and 
damp is more common. The latest statistics I have seen are those of 
Loew l and Ramsperger, 2 collected from the records of Aid Societies. 
Loew's were of 167 simple fractures of the leg; only one was perma- 
nently disabled, the others regained their earning capacity in an average 
of 101 days, 70 per cent, in 91 days each. 

Ramsperger's, of 145 fractures of the leg, given in more detail, 
show complete earning capacity, after simple fracture of the shaft 
of both bones healed without deformity, restored in most during the 
first six months, in a few not until the third or fourth year ; in those 
that healed with deformity (36 per cent.) the restoration was complete 
in 29 per cent., in the remainder the loss was generally less than 25 
per cent. Of the compound fractures of the shaft complete restora- 
tion followed in 32 per cent., the loss in the remainder was usually less 
than 25 per cent. 

Of the simple fractures of the malleoli there was recovery without 
deformity in 61 per cent., with deformity in 39 per cent. ; of the 
former, restoration was complete in 75 per cent., of the latter, in 23 per 
cent. Two-thirds of all resumed work during the first six months, 
one-third during the second six months. After compound fracture 
there was always some loss. 

1 Loew: Deutsche, Zeitschrift f. Chir. vol.xliv. Abstr. in Centralb. f. Chir., L897, p. 855. 

* 2 Ramsperger : Korresp. des Wiirtenib. iir/.t. Landesvereins. Abstr. in Centralb., L897j 
p. 735. See also Morian : Arch, klin. Chir., vol. St. ii. p. PS. 



126 FRACTURES. 

After fractures of the fibula restoratiou was always complete, but 
sometimes much delayed. 

Sauer * iu 111 cases of fracture of one or both bones of the leg or of 
one or both malleoli (Pott's), found complete restoration of earning 
capacity in 75 per cent, after 16.4 months. The percentage varied 
from nearly 100 in patients under twenty years of age to about 33 per 
cent, in those over fifty years. 

All these statistics are taken from the records of relief associations, 
the patients receiving aid according to the degree and continuation of 
the disability. 

The more unfavorable estimates of results in respect of earning 
capacity, notably those of Lane, are entirely out of accord with my 
own experience and observation. I recently sent letters to all the 
patients who had been treated in the New York Hospital for fracture 
of the lower limb during the previous year and received answers from 
twenty-six as follows : Neck of femur, 3 ; limb nearly useless. Shaft 
of the femur, 4; limb as useful as before the injury. Leg, 10; in 7 
as good as ever, in 3 good, but with some pain. Pott's fracture, 9 ; in 
6 as good as ever, in 2 fairly good, in 1 bad. 

A painstaking and valuable study of the late results after fracture 
of the thigh, based on a hospital service of three years was made by 
Ashhurst and Newell. 2 Of 1 9 elderly and 2 young patients with fracture 
of the neck of the femur 13 had entirely useful limbs, 6 walked with a 
decided limp (some using a cane or crutch) and 2 were incapacitated. 
Of 31 fractures of the shaft 19 had a perfect functional result, 10 a 
limp but no disability, and 2 (subtrochanteric fracture with 2 inches 
shortening) marked impairment. Nine fractures of the condyles gave 4 
perfect functional results, 3 with limp but no disability, and 2 inca- 
pacitated. 

1 Sauer : Beitrage zur klin. Chir., vol. 46, p. 184. 

2 Ashhurst and Newell : Annals of Surgery, 1908, vol. 48, p. 748. 



CHAPTER X. 

FRACTURES OF THE SKULL. 

The function of the cranium is so largely limited to mechanical 
protection of the brain and its annexa from external violence, its frac- 
ture in a great majority of cases involves after recovery so slight an 
interference with this function, and treatment can do so little to dimin- 
ish this interference, that the importance of the injury lies almost 
wholly in the associated injury of the brain and in the later inflam- 
matory or degenerative processes therein to which that injury or that 
of the overlying soft parts may give rise, and its consideration falls in 
the majority of cases rather under the rubric of injury of the brain 
than under that of fractures. It is unfortunate that these injuries 
should be so universally classed as fractures, for this leads to an 
undue fixing of the attention upon the lesion of the bone to the exclu- 
sion or minimizing of that of the brain and to undeserved reproach for 
occasional failure to recognize the presence of fracture. It should be 
remembered that the violence which causes fatal injury of the brain 
together with fracture of the skull may, under slightly changed con- 
ditions, cause the former without the latter, and that in a large propor- 
tion of fatal cases the fracture is merely an incident without any direct 
relation to the fatal result or only with that of having made the causa- 
tive lesion possible. On the other hand, there is a class of fractures 
in which the lesions are entirely local and limited to the bone and the 
overlying soft parts, or in which, if the contents of the cranium are at 
all injured, the injury is limited to the immediate neighborhood of the 
fracture. In these the fracture is the essential lesion, and the treatment 
is almost wholly directed to it. Between these two forms — generalized 
contusion of the brain and its envelopes, with or without fracture, and 
circumscribed fracture with or without localized injury of the brain or 
meninges — there are others in which the character of the fracture and 
its mode of production are exaggerations of those of the second group, 
and the effect upon the contents of the cranium those of the first group. 
In the first group the fracture is usually fissured and almost always 
occupies or extends to the base of the skull, and hemorrhages covering 
a large area though limited in amount of extravasated blood are found 
upon the surface of the brain and sometimes within it and the medulla, 
indicating contusion ; in the second the type is a compound circum- 
scribed depressed fracture, possibly with a rent in the underlying dura ; 
in the intermediate class there are the comminution of the second (but 
more extensive and associated with fissure) and the hemorrhages and 
the contusion of the first. In the production of the first the causative 
violence acts broadly upon the skull, modifying its shape through its 
elasticity and perhaps splitting it by exceeding the limits of that elas- 

127 



128 FRACTURES. 

ticity, and bruising its contents by that modification of the shape and 
by the jar, as in a fall; in the second, as in a blow of a hammer, the 
force is consumed in breaking the bone at the point of impact, there is 
no general change in the shape of the skull, no diffused effect upon 
the brain as a whole. Because of the mode of production fractures of 
the second group are usually compound. In the intermediate group 
the violence is greater than in the others, it breaks a larger area of 
bone and is not exhausted in producing the fracture. This difference 
in the mode of production and in the effects of the violence dominates 
the whole subject and determines the treatment and the prognosis. 
All this appears plainly in study of the mechanism, pathology, and 
cause of the injury in the various forms. 

Mechanism and Pathology. 

In studying the mechanism of fracture certain anatomical features 
of the cranium must be borne in mind. Of the vault and base of 
which it is composed in unequal parts, the former is globular, thick, 
and elastic ; the latter is flattened, irregular, thick in places, thin in 
others, and perforated at many points for the passage of nerves and 
vessels. From the occipital condyles, by which it rests upon the 
spinal column, pass outward, backward, and forward various thick 
portions or ridges constituting a strong framework to connect them 
with the vault ; the basilar process and body of the sphenoid, the 
occipital crest, and the petrous portions of the temporal bones ; further 
forward are the thicker portions of the greater and lesser wings of the 
sphenoid and the frontal crest. To a certain extent these ridges direct 
lines of fracture of the base to the thinner intermediate segments, but 

Fig. 52. 




Sword cut ; fissured fracture. (Konig.) 



all can be crossed by them. The vault, which varies greatly in thick- 
ness at different points and in different individuals, has a thick outer 
and a thin inner table of dense bone separated by the spongy diploe. 
The physical characteristic of the vault which most concerns us is its 



FRACTURES OF THE SKULL. 



129 



elasticity, which is sufficient to permit a considerable change of shape 
without fracture — that is, a diameter of the skull can be shortened and 
those at right angles to it lengthened by compressing it in a vise, or a 
portion of its surface can be momentarily flattened by a blow. 

The effect of violence acting upon the skull varies with its character 
and the size and shape of the vulnerant body, and appears in all the 
gradations between a slight crush or cut of the outer table or of the 
entire thickness of the bone, through circumscribed depressed areas 
to single or multiple fissures running completely around. A cutting 
instrument, as a chisel or sword, cuts partly or entirely through the 
bone and by its wedge-action may produce long fissures running from 
each end of the cut if the weapon is heavy and the blow powerful 
(Fig. 52), or, if the instrument changes its direction, it may break off 
a piece of the bone and raise it above the level. 

A moderate blow with a pointed or edged weapon may simply break 
the outer table, where the bone is thick, and depress it by crushing the 
underlying diploe, or, if the bone is thin, it may make a small rounded 
hole in it without splintering or Assuring of the side. If the instru- 
ment is not sharp or edged the bone is bent inward and the effect varies 
with the force of the blow and the prolongation of its action. In the 
slightest form the elasticity of the skull takes up and distributes the 
force without recognizable injury to the bone. If the force is a little 
greater the inner table, which is overbent in the movement, splits away 
from the diploe and is broken (frac- 
ture of the inner table alone), the 
unbroken portion springing back to 
its original position and leaving the 
fragment more or less removed and 
changed in position. The same effect 
has been produced in the outer table 
by a blow from within, as by a bullet 
that has traversed the skull from the 
opposite side. 

If the force is still greater the 
bone is broken entirely through to 
an extent and in directions that vary 
widely, and the circumscribed por- 
tion remains more or less depressed. 
If the lines of fracture do not en- 
tirely circumscribe the affected area the elasticity of the unbroken 
portion brings back the depressed piece toward or to its place (Fig. 
54), sometimes imprisoning in the fissure a few hairs or a portion oi' 
the head covering. If the circle of fracture is complete the enclosed 
portion remains depressed, either bodily or, more commonly, with 
sloping sides (Fig. 55). From the edge of the opening, small fissures 
or circumscribed lines of fracture frequently run. The inner table i> 
always more extensively broken than the outer one, and the two are 
largely separated from each other by planes of fractures through the 
diploe (Fig. 56). These fractures are almost always compound 
because of the character of the causative violence, the skin yielding 



Fig. 53. 



i 




Mechanism of fracture of the internal table 
by bendinsr of the bone. 



130 



FRACTURES. 



under it as the bone does. They are part of the so-called " compound 
comminuted depressed fractures of the skull." 

All of the injuries thus far described belong in what are termed the 
second group in the opening paragraph of this chapter, those in which 



Fig. 54. 




Circumscribed fracture with inclusion of hair. (Konig.) 

the dominant feature is the fracture and in which injury to the brain 
is usually absent or strictly localized. This feature is of so great prac- 
tical importance that I wish it might be indicated in the classifying 



Fig 




Circumscribed depressed fracture. (Konig.) 



nomenclature, to the exclusion, or at least the great subordination, of 
" depression," which has long held the attention of the surgeon, to the 
hopeless confounding of radically different cases and the useless or 



FRACTURES OF THE SKULL. 



131 



harmful generalization of therapeutic measures the value of which is 
strictly limited. I have long sought such a name that would be dis- 
tinctive and short; possibly " circumscribed fracture of the vault" 
would serve the purpose, although it is far from meeting all the indi- 
cations. 

The vast majority of fractures of this class involve the vault, but 
they occasionally occur at the base, the vulnerant body reaching it 
through the mouth or orbit, and in a very few cases even the condyle 
of the lower jaw has been driven through the roof of its socket, or 
the ethmoid driven in by a blow on the nose. The prognosis is worse 
in these basal cases because important parts of the brain are usually 
injured, efficient treatment is impracticable, and infection is more 
likely to occur. 



Fig. 56. 



Fig. 57. 




Circumscribed depressed fracture, inner side 
healed. (Konig.) 



Fracture of internal table. 
(Bergmann.) 



The other group of fractures, those produced by a force acting 
broadly upon the cranium to modify its shape as a whole, include 
almost all fractures of the base, and all so-called " indirect fractures " 
and " fractures by contrecoup" which have had so large a part in the 
discussion of this subject. In these, I repeat, the important lesion is 
that produced in the brain ; the fracture is an incident, it usually has 
no influence upon the progress of the case and gives rise to no thera- 
peutic indications. Similar brain lesions can be produced without 
fracture, and these cases belong among injuries of the brain rather 
than among fractures. This makes a detailed account of the mam 
forms, their relative frequency, and their more or less hypothetical 



132 FRACTURES. 

relations to different forms of violence unnecessary in a work of the 
scope of this one. 

The mode of production of these fractures has been the subject of 
close observation, experiment, and study by many, among whom I 
shall mention only Aran, Felizet, Messemer, and Von Wahl. Another, 
Duret, 1 deserves to be remembered, perhaps above all others, for his 
remarkable investigations and his theory of mechanism by which the 
changes of shape of the cranium produce the often distant lesions of 
the brain and meninges, a theory which, even if carried in its details 
somewhat further than it can readily be followed, and possibly even 
incorrect, has yet been most valuable in fixing the attention upon the 
intracranial lesions and clearing away a large amount of nebulous 
theories concerning distant effects and their hypothetical causes. 

The theory of these fractures as now apprehended is based in part 
upon the shortening of the diameter in the direction of the violence 
and the consequent lengthening of those at right angles to it, and in 
part upon the overbending of the bone under a like strain. In a 
globular body of uniform elasticity the shortening of one diameter 
under pressure is necessarily accompanied by the enlargement of the 
mass in the line of the equator and in the corresponding separation 
of the meridians. If the limit of cohesion is passed, separation (frac- 
ture) necessarily takes place between two or more meridians, and the 
line of fracture runs approximately from pole to pole — that is, from 
the point struck to one diametrically opposite — along a meridian. To 
these Messemer gave the name of " bursting fracture." Thus, in the 
skull, a blow received in the centre of the frontal bone and directed 
backward would shorten the antero-posterior diameter and enlarge the 
skull in the central transverse plane at right angles to the line of force, 
and, if strong enough, produce one or more fissured fractures running 
from before backward along the summit or side of the cranium. If 
the blow were received upon the side the lines of fracture would be 
transverse through the vault or base or both. 

Under other circumstances not fully understood, but probably de- 
pendent upon lack of uniformity in or differing degrees of elasticity, the 
yielding along the line of impact is not so fully or so promptly met by 
expansion in the other plane, and the bone breaks at the point of maxi- 
mum curvature at the periphery of the depressed area and along what 
may be termed a parallel of latitude, at right angles to the line of force, 
producing what Von Wahl names a "bending fracture." Thus, a force 
acting from before backward upon the centre of the frontal bone would 
produce this form of fracture along a line crossing the cranium from 
side to side. 

The lines of fracture produced in these two ways are modified by 
lack of uniformity in the shape and structure of the cranium and by 
the degree of the fracturing force; the majority of those involving the 
base and limited to a single zone occupy the middle fossa, and in those 
not limited to a single zone the violence appears to have been greater, 
and the portion of the vault which has received the blow shows ex- 

1 Duret : Etudes Experiruentales et Cliuiques sur les Trauniatisrues Cerebraux, Paris, 

1878. 



FRACTURES OF THE SKULL. 133 

tensive splintering (Von Bergmann). The direction of fissures lim- 
ited to the middle fossa is in the great majority of cases transverse, 
following one of two paths, either in the anterior part of the petrous 
portion of the temporal bone, parallel to its long axis and opening into 
the middle ear, or further forward in the great wing of the sphenoid. 
The cause is a blow upon the vertex or the side of the skull, and the 
fracture ends in the foramen lacerum anterius or in the sphenoidal 
fissure. If the force is greater the fracture may extend across the 
sella turcica into the opposite middle fossa, or obliquely through the 
sphenoid into the opposite anterior fossa, or into the anterior fossa of 
the same side. Fractures of the posterior fossa, caused by a blow on 
the occiput, are rarely limited to it, but cross the petrous portion to 
the middle fossa, but never cross the occipital ridge ; and those of the 
anterior fossa usually pass through the upper margin of the orbit and 
run back to the optic or sphenoidal foramen, extending sometimes across 
the middle into the posterior fossa, sometimes also across the cribriform 
plate to the other orbit (Konig). In crushing fracture of the bones of 
the face longitudinal fracture of the base along the body of the sphe- 
noid appears to be frequent. 

That most of the fractures produced in this manner occupy the base 
with but little or no extension to the vault is to be explained by the 
less resistance of the base due to its relative thinness and its irregu- 
larity of shape and also, possibly, in part to the impinging force or the 
resistance of the body exerted upon the base by the spinal column 
through the occipital condyles. When the vault is more extensively 
involved the line of fracture may cross it completely in any direction 
either as a long fissure with little change of place or with a separation 
so free that the two halves of the skull can be freely moved upon each 
other. The internal table shows no splintering. The short isolated 
fissures distant from the point struck, which are seen not infrequently 
in the base and occasionally, but very rarely, in the vault, are produced 
in a variety of ways and will be considered in the following paragraph 
among the exceptional forms. Most of the extensive fissures of the 
vault belong in what was spoken of in the opening paragraph of this 
chapter as the group of fractures intermediate between the two main 
groups, those in which the causative violence is great and produces 
extensive crushing fracture at the point struck, with radiating fissures 
and generalized lesion of the brain. They are sometimes, but not 
always, compound. 

Exceptional forms of fracture, the mode of production of some of which 
is very obscure, are found at many points. The small isolated fissures 
at a distance from, or even directly opposite, the point struck, to which 
the name " fracture by contrecoup" was given, belong almost all 
among the "bursting "or "bending" fractures, those of the base 
(when the blow has been received upon the vertex) being due to the 
resistance of the spinal column acting through the occipital condyles. 
The cases in which the fracture is directly opposite the point struck 
are so few and so doubtful that their existence has been denied, yet 
Perrin produced experimentally a fracture of the frontal bone by 
throwing a skull upon its occiput, and therefore the possibility must 



134 FRACTURES, 

be admitted. Inclusion in this group of fractures at such a point pro- 
duced by a second blow directly upon it, as when a fracture of the 
occiput is caused by a fall upon the back of the head following a blow 
upon the forehead, is, of course, unjustifiable. A special group of 
nine cases collected by Yon Bergmann l in which the orbital plate was 
broken is of great interest. In four cases the primary violence was 
by a glancing bullet, in the others a bullet penetrating the temporal 
(3), the occipital (1), and the parietal (1). In some only one orbital 
plate was broken, in others both ; the fracture was either a straight 
fissure or circular ; in President Lincoln's case 2 (perforation of the 
occipital by a bullet) both plates were broken and the fragments 
" pushed up toward the brain ;" in two the fragments were depressed 
a few millimetres into the orbit. In an allied case a perforating bullet 
wound of the right parietal was accompanied by a fissure extending 
from the sella turcica through the great wing of the sphenoid. The 
explanation offered by Longmore 3 and Von Bergmann is by moment- 
ary excessive intracranial pressure produced by the penetration of the 
ball or the bending inward of the vault. 

Fracture of the posterior clinoid processes is occasionally observed, 
evidently produced by traction upon them by the attached tentorium 
during elongation of the antero-posterior diameter of the skull. 

The so-called " ring fractures " about the foramen magnum caused 
by a fall upon the feet or buttocks are due to the impact of the skull, 
through the occipital condyles, upon the upper end of the spinal col- 
umn, just as, to use Felizet's comparison, the head of a hammer is 
driven firmly down upon its handle by striking the other end of the 
latter against the ground. 

Exceptional isolated fractures of the base by direct violence have 
been referred to, such as those produced by the passage of a bullet, a 
stick, or a knife through the orbit or the mouth, fracture of the 
ethmoid by a blow upon the nose, or fracture of the temporal by the 
pressure of the condyle of the inferior maxilla in a blow upon the 
chin. Fracture of the anterior Avail of the auditory canal by the same 
cause deserves mention because of the bleeding from the ear which it 
occasions and which may be mistaken for that following fracture of the 
petrous portion of the temporal bone. These fractures owe their impor- 
tance to the associated injuries of the contents of the cranium, espe- 
cially of the carotid artery and cavernous sinus in wounds through the 
orbit, and to the possibility of the spread of infection from the outside 
to the interior. 

Fractures of the Internal Table. These are apparently extremely rare. 
In the Medical and Surgical History of the War of the Rebellion twenty 
cases observed during the war are recorded and brief notes are given 
of twenty-nine cases reported during the preceding two hundred years. 
Von Bergmann describes three additional specimens. In the great 
majority of the reported cases the cause was a blow by a glancing 
bullet which exposed the bone but left the outer table uninjured or 
only grooved or contused ; among the other causes are blows with small 

1 Von Bergmann : Deutsche Chirurgie, Lief. 30, p. 211. 

2 Surg. Hist. War of the Rebellion, vol. i. p. 305. 3 Lancet, 1865, vol. ii. p. 649. 



FRACTURES OF THE SKULL. 135 

round objects, such as a hammer, a cricket-ball, a beer glass ; in only 
one case was the cause a fall upon the head. The alleged greater 
brittleness of the internal table appears to be entirely foreign to this 
limitation of the effect of the blow, the cause of which is the over- 
bending of the table as described above. 

The fracture may be a simple fissure, one side of which is slightly 
depressed, or circumscribing and detaching a scale of bone, or, more 
commonly, a comminuted one with a marked central depression (Fig. 
56). The dura may be torn or the small fragment may be forced 
entirely through it. In one case the middle meningeal artery was torn. 
In some of the cases close examination after death has shown a slight 
fissure of the outer table and diploe. As almost all the reported cases 
have ended fatally, usually in consequence of suppuration of the super- 
ficial wound and extension of the infection to the interior of the cra- 
nium, it is possible that many other cases not thus complicated have 
ended in recovery and passed unrecognized ; the inference then would 
be that the danger to life lay not in the fracture or in the displacement 
of a fragment but in the coexisting wound and the spread of infection 
from it. 

The coincident injuries of the contents of the cranium are rupture of 
the dura and pia, laceration and contusion of the brain, rupture of 
arteries, venous sinuses, and cranial nerves, and multiple extravasations 
of blood from the smaller vessels on the surface of the brain and ven- 
tricles and less frequently in its substance. 

The dura is rarely torn except when the fragments are notably driven 
inward, and then only to a moderate, extent. Direct contusion and 
laceration of the brain, recognizable macroscopically, is found only 
under the same circumstances, but there is reason to believe that even 
in the slighter cases it receives a contusion which makes it peculiarly 
liable to be secondarily affected by infection proceeding from suppura- 
tion of the adjoining scalp ; that is, central abscesses and cysts which 
are probably not the remains of hemorrhages are occasionally observed, 
the former after suppuration of the scalp, the latter after even simple 
fracture. 

The hemorrhages from the vessels of the pia which are constant in 
the "bursting" and " bending " fractures are attributed by Duret to 
rupture of the smaller vessels by the sudden forced shifting of the 
cerebro-spinal liquid under the influence of the blow and the change 
in the shape of the skull thereby produced, by which certain portions 
of the space in which it is contained are sharply distended and the 
connected vessels torn. The effects are seen not only on the surface 
of the brain or in the subarachnoid space but also within the cortex 
and in the ventricles, especially the fourth, and it is to these that many 
of the cerebral symptoms are to be attributed. This also is the expla- 
nation of the presence of the hemorrhages found at points distant from 
the one struck. 

Rupture of the middle meningeal artery is followed by increasing 
extravasation of blood, usually between the dura and the skull, with 
quite characteristic symptoms and the possibility of relief by operation. 

Rupture of the cavernous sinus, and more rarely of the carotid artery 



136 FRACTURES, 

where it lies within it, is seen in some fractures of* the base and espe- 
cially in those due to the entrance of the vulnerant body through the 
orbit. Occasionally an arterio-venous aneurysm results. The other 
sinuses may also be torn when the line of fracture crosses them, but 
the complication seems rarely to be important. 

Laceration of a cranial nerve is rare ; the facial most frequently. 
But interference with function by hemorrhage into the sheath of a 
nerve is more common. 



Pathological and Reparative Processes following Fracture. 

These differ radically according as infection is present or absent, and 
while this difference does not exactly coincide with that of simple and 
compound fractures, yet the existence of an open wound in communi- 
cation with or even near the fracture creates dangers which are almost 
wholly absent from simple fractures. 

Kepair of the fracture is effected largely by the diploe, and although 
the pericranium and dura can each produce bone they usually do so to 
only a slight extent, and consequently an overgrown callus is rare. 
Moreover, the osteogenetic action is rarely sufficient to close even a 
small gap in the bone, so that gaps created by the removal of frag- 
ments or trephining are habitually closed only by fibrous tissue with 
at the most a small margin of new bone along the edge of the opening. 
And yet in a case in which I removed fully two square inches from 
the frontal bone, broken by a blow with a hammer, I found twenty- 
five years afterward firm, apparently bony, resistance over the entire 
area. Depressed fragments heal in the position in which they are left, 
and large broad depressions in infants will often be diminished by 
intracranial pressure. 

Persistent depression in the motor area may maintain a correspond- 
ing paralysis by its local pressure upon the cortex, but the weight of 
surgical opinion at the present time is opposed to the belief that it has 
any marked influence in producing irritation or other functional dis- 
turbances, such as epilepsy. 1 It has been abundantly shown clinically 
and by experiment that the brain readily accommodates itself to a 
marked diminution of the cranial capacity, and that even a sudden 
diminution must amount to about two cubic inches in the adult skull 
before it can of itself produce permanent symptoms of general com- 
pression. In very few fractures is the depression as great as that, and 
the symptoms which accompany it rarely differ from those of other 
fractures with little or no depression. That cerebral symptoms have 
been promptly relieved by the removal of a depressed portion of bone 
does not prove that the depression was their cause, for similar relief 
has often been given by the removal of portions that were not depressed 
or in any way altered, and even by operations on distant parts of the 
body. The clinical grounds for the belief that the scar following 
removal of a portion of the skull is able to cause functional disorders 
are as good as those that a persistent depression can do so. It seems 

1 See Von Bergmann, Konig, Hutchinson, in London Hospital Beports, vol. vi. ; Eche- 
verria, Arch. Gen. de Med., 1878. 



FRACTURES OF THE SKULL. 137 

probable that if the dura is torn, and intrameningeal adhesions thereby 
produced, the chances of chronic irritation and functional derangement 
are greater than if such adhesions do not exist. 

Contusion of the brain and laceration of its vessels and of those of 
the pia, in. uncomplicated cases in which the patient survives the pri- 
mary injury, heal kindly, and the cases in which they give rise to a 
meningitis of any extent or importance are very exceptional. The 
extravasated blood is absorbed, or occasionally remains as a cyst. 
Occasionally, but very rarely, suppuration takes place beneath a simple 
fracture, just as it does in closed injuries in other parts of the body. 

Generalized contusion of the brain, as seen in the "bursting" and 
" bending " fractures and in those of the intermediary group, is gen- 
erally fatal, but not through meningitis. The lesions are more exten- 
sive than those of most apoplexies and apparently they kill in like 
manner. Even in fractures of the base with rupture into the middle 
ear the cases in which an intracranial infection has originated through 
this communication with the exterior are, in my experience, very rare. 
It is the cerebral lesion that kills, not the fracture or any secondary 
result of the fracture. 

In compound fractures when infection is avoided repair goes on in 
the same manner ; but if the wound suppurates the infection may spread 
not only to the bone but also, as in cases of phlegmon without fracture, 
to the interior of the cranium by lymph channels, connective tissue, 
and thrombi in the veins, and thus give rise to suppurative meningitis 
and pyaemia. In short, the progress of a case is determined mainly 
by the character and extent of the intracranial lesions and the pres- 
ence or absence of infection, and the fracture, as such, usually has but 
little influence upon it. 

Symptoms, Diagnosis, and Treatment. 

The distinction which has been made between those cases in which 
the fracture is an important, perhaps the principal, lesion and those in 
which it is only a comparatively unimportant accompaniment of grave 
lesions of the brain and its annexa must here be kept constantly in 
mind. Fortunately, in the former, in which the recognition of the 
fracture is important because of the therapeutic indications which arise 
from it, the diagnosis is usually easy ; and in the latter, in which the 
fracture seldom demands or can receive any direct treatment or affects 
in any way the prognosis, and in which the practical interest is limited 
to the intracranial injuries, the fact that the existence of a fracture can 
only be inferred, and not be demonstrated, does not leave us less able 
to do all that can be done for the patient. Instead, therefore, of fol- 
lowing the usual division of the subject — fractures of the vault and 
fractures of the base — I shall use that of circumscribed fractures of the 
vault and fissured fractures with generalized brain injury i with separate 
consideration of the rarer forms which lie outside of this grouping. 
Furthermore, as diagnostic and therapeutic measures in many eases 
run closely together or even coincide, I shall at the same time consider 
the treatment. 



138 FRACTURES. 

Circumscribed Fractures of the Vault. 

As these fractures are produced by a blow from a relatively small 
body or from one having an edge or corner, the fracture is often com- 
pound and the diagnosis is made' by direct inspection and palpation of 
the bone. In most cases there is no difficulty ; the fragments can be 
seen and felt at the bottom of the wound, and it remains only to deter- 
mine the extent of the fracture and apply the appropriate treatment. 
In the doubtful cases the bone has to be carefully examined in search 
of a fissure, or its condition and the character of the violence con- 
sidered as bearing upon the probability of a fracture of the internal 
table. 

In respect of a fissure the edge of the torn periosteum can easily be 
mistaken for one by touch, or a cranial suture by the eye. The error 
in the first case is so easily made, even when one is on his guard against 
it, that the finger should not be trusted ; in the second the fissure can 
generally be recognized by its bleeding, when fresh or when rubbed. 
The importance of its recognition comes from its possible indication of 
more extensive fracture beneath and from the frequent advisability of 
enlarging it for thorough disinfection. 

When the bone is distinctly broken and depressed, even when the 
area is small, the depressed portion should be raised. If it proves to 
be only a fracture and depression of the outer table the operation needs 
to be carried no further ; the wound is washed and closed. . If the 
entire thickness of the bone is broken the deeper as well as the super- 
ficial fragments must be removed. It is rarely necessary to use a 
trephine for this purpose, for the corner of a chisel or elevator can be 
engaged under the edge of a fragment and thus raise it, and after one 
piece has been removed the removal of the deeper ones is easy, for they 
can be grasped with forceps and withdrawn by careful traction ; the 
amount of internal table removed is usually greater than that of the 
outer table. If the dura is torn, and there is no bleeding from the pia, the 
opening in the dura should be closed with catgut sutures ; if there is 
free bleeding from the pia the wound should be packed with gauze for 
a few hours, after which the opening in the dura may be closed. The 
overlying soft parts, including the pericranium as far as possible, should 
be closed with sutures, a small gauze drain being inserted and main- 
tained for a day or two. The scalp should be shaved for some distance 
about the w T ound and thoroughly disinfected by scrubbing and washing 
with bichloride before anything is done to the bone. 

When the gap left by the removal of bone is large and the wound 
is clean a thin sheet of aluminum, celluloid, rubber tissue, or foil cut 
to fit it may be inserted in it. The softer materials seem to answer as 
well as the firmer ones by leading to the formation of a thick and 
tough cicatrix. Gold foil or rubber tissue has sometimes been placed 
beneath the torn dura to prevent meningeal adhesions, but either is 
liable to induce exaggerated cicatricial formation. Freeman has lately 
recommended the use of the lining membrane of an egg. 

Brewitt 1 has recently (1906) published a series of remarkable results 
obtained by replacing the fragments and closing the wound over them. 

1 Brewitt : Arch, fur klin. Chir., vol. 79, p. 47. 



FRACTURES OF THE SKULL. 1 39 



Of 38 cases 2 died ; in all the others primary healing took place, and 
in 28 of them the fragments united solidly on a level with the adjoin- 
ing bone ; in the others there was some depression of the surface. He 
also claims, with statistics in support, that patients thus treated are 
also more free from late ill effects. 

In small perforations, as by a nail or even by the end of a small 
stick (the handle of a paint-brush in one of my own cases), the open- 
ing must be enlarged by the chisel or trephine for the better cleaning 
of the deeper parts of the wound ; and in pistol-shot fractures this is 
also necessary, but only for the same purpose and for the removal of 
the ball, if it is within easy reach, and of small fragments. Bullets 
can heal in, and without giving rise to late consequences ; and I think 
the risks of attempts to remove a bullet are greater than those of leav- 
ing it in place if the orifice of entry is the only communication with 
the exterior and can be thoroughly cleaned. If the bullet in its pas- 
sage has opened the ethmoid cells or the frontal sinus infection from 
that side is probable and the bullet should be removed if possible, but 
whether it is removable or not the prognosis is thoroughly bad. 

In any of these cases there may be free hemorrhage from within the 
cranium and escape of brain tissue, or, very rarely, a flow of cerebro- 
spinal liquid coming from the subarachnoid space or even from the 
lateral ventricle. Bleeding from a wounded sinus can be arrested by 
lateral ligature or suture or by packing. 

Circumscribed depression without wound of the soft parts may be recog- 
nized by the finger, which when carried firmly along from the adjoining 
bone appreciates the change in level, but a very similar sensation is 
given by the swollen circular margin of a deep contusion ; that is, the 
finger passes over a firm rim to a soft central area which suggests 
depression. Error can be avoided by making firm pressure on the 
hard margin and then passing slowly toward the centre; the margin 
yields under the pressure and the finger recognizes the level resistance 
of the bone throughout. 

In these cases, as in the preceding, general symptoms — cerebral shock 
or contusion — may be slight, transient, or absent ; the stunning, the 
partial or complete unconsciousness passes and is perhaps followed by 
nausea and headache ; if they are more than this they indicate gener- 
alized lesions that bring the case into the intermediate group, to be 
subsequently considered. If the depression is immediately over a por- 
tion of the motor area or a special centre there may be a corresponding 
paralysis or abolition of function. Very rarely a fluctuating tumor 
may form under the skin which on puncture proves to contain cerebro- 
spinal liquid that has escaped through the torn dura. This has been 
observed only in young children. 

In the treatment of these simple circumscribed fractures with depres- 
sion there are two things to be considered : the effect upon the brain and 
meninges if the depression persists, and the risks involved in relieving 
it. The reasons have been given above for the belief that persistent 
depression is not often responsible for the late functional disturbances 
that have been attributed to it, and that consequently it does not, in 
the absence of special indications, imperatively require relief. But, 



140 FRACTURES. 

on the other hand, although it is properly urged that the unbroken 
skin is a safer protection against infection than the strictest asepsis 
(Konig), yet the danger incurred in making an opening in the vault of 
the cranium, especially if the dura is not wounded, is so slight that I 
cannot criticise those who act upon the conviction that it is less than 
those of persistent displacement even when the disadvantages of the 
resultant gap are taken into account. This applies only to' small areas 
of depression and the removal of only a small portion of bone. The 
special indications referred to, which call for operation, are found in 
the evidences of localized pressure or of hemorrhage from a branch of 
the middle meningeal artery. (See below.) The value of a localized 
symptom (monoplegia, etc.) is much greater in a fresh injury than 
when it occurs after the lapse of a few days, for in the latter case it 
may be due to the spread of inflammation from a primary focus at 
some little distance from the centre which corresponds to the paralysis. 

Fissured Fractures with Generalized Brain Injury- 

These, let me repeat, are the " bending " and " bursting " fractures 
produced by violence acting broadly upon the skull, changing its shape 
temporarily beyond the limits of its elasticity, and causing contusion 
of the brain with larger or smaller hemorrhages especially upon its 
surface. In the great majority the fracture occupies or extends to the 
base of the skull, and the injury is hence generally spoken of as fracture 
of the base. The principal injury is the lesion of the brain, and the 
associated fracture is mainly of importance as indicating that the injury 
to the brain is probably extensive and grave. The opinion long held 
that fractures of the base were necessarily fatal has been shown to be 
exaggerated, 1 but yet the percentage of mortality is high, and similarly 
produced fractures of the vault have a like gravity. In ten years — 
1895-1904 — 319 cases of fracture of the base were treated at the 
Hudson Street Hospital, with 206 deaths. The chief symptom of 
the brain injury is unconsciousness, more or less complete, with the 
history of a blow, irregularity of the pupils, and a moderate rise 
of temperature. There may also be the signs of compression : slow- 
ing of the pulse, increase of bloodpressure, and choked disc. The high 
temperatures which have been spoken of as constant, 105° to 107° F. 
(Phelps), I have seen only in the few hours before death. Paralytic 
symptoms and symptoms connected with the circulation and respiration 
depend upon the portions of the brain and medulla involved in the injury. 

The differentiation is from other forms of coma, especially the alcoholic, 
and is often extremely difficult or even impossible, as when alcoholism 
coincides with trauma. The points of diiference (with many exceptions) 
are that in alcoholic coma the temperature is not raised, the unconscious- 
ness is less deep, the pupils are equal and responsive. It must always 
be remembered that the two conditions may coexist. 

1 Graf (Deutsche Zeitschrift fur Chir., vol. lxviii., p. 464) gives statistics of 90 cases 
of fracture of the base treated at the Charite in Berlin between 1896 and 1902, includ- 
ing the condition after recovery in 48 of them. There were 34 deaths. The most 
common late result was diminution of the hearing in 27 of 39 cases examined. In 2 
there was persistent facial paralysis. 

140 



FRACTURES OF THE SKULL. 141 

During the past year I have withdrawn by lumbar puncture a few 
drops of the cerebrospinal liquid in many cases of unconsciousness due 
to various causes, in the hope of finding that the presence or absence 
of blood in it would aid in the differential diagnosis. Blood was almost 
invariably present in fracture of the skull, and also in many apoplexies. 
The diagnostic value of its presence is considerably diminished by the 
fact that it is caused not infrequently by the puncture itself, presumably 
by wounding a meningeal vein. 

The symptoms belonging to the fracture itself are hemorrhages, 
ecchymoses, occasionally a watery discharge from the ear or nose, and 
deafness of the ear of the affected side. 

Hemorrhage from the ear, nose, or mouth is frequent, that from the 
ear being almost pathognomonic of a fracture through the petrous por- 
tion of the temporal bone ; it is usually slight but may be profuse. 
Konig refers to a case in which the flow from the middle ear through 
the Eustachian tube into the mouth was so abundant that he felt obliged 
to do tracheotomy to prevent suffocation. Bleeding from the ear which 
may be mistaken for that of a fracture of the base may be due to rup- 
ture of the membrana tympani or to injury of the external auditory 
canal by a blow upon the chin which has forced the condyle of the jaw 
backward, or even to a fissure of the vault extending to the mastoid 
process. 

Ecchymosis at certain points, not due to direct contusion, is signifi- 
cant of fracture. A frequent one is that beneath the ocular conjunctiva, 
spreading to that of the lids and then to the skin of the latter ; it 
is most constant and marked in fractures of the orbital plate and 
sphenoid. A slight ecchymosis behind the ear is often found after a 
day or two. 

A watery discharge from the ear after fracture of the base is not 
infrequent and is sometimes very profuse (in one case 63 ounces in 
four and one-half days). Four varieties differing in the amount and 
character of the discharge have been observed : (1) The flow is abun- 
dant and prolonged, the liquid contains a large proportion of chloride of 
sodium and but little albumin, and is then doubtless the cerebro-spinal 
liquid of the subarachnoid space and sinuses escaping through frac- 
ture of the internal auditory canal and rupture of the tympanum. (2) 
The flow is similar, but the liquid is highly albuminous and without chlo- 
ride of sodium ; autopsy in some cases has shown a fracture through the 
middle and internal ear but not through the internal auditory canal ; 
the liquid is probably lymph coming from the large arachnoid lymph- 
space which normally communicates with that occupied by the peri- 
lymph of the labyrinth or liquid Cotunnii. (3) The flow is abundant 
and albuminous, becoming scanty and purulent ; probably an inflam- 
matory discharge from the surface of the cavity of the tympanum. 
(4) The flow is scanty, appears late, is albuminous and reddish, and is 
probably the serum of extra vasated blood. 1 

Deafness of the ear of the affected side is due to injury of the middle 
or internal ear or of the acoustic nerve in its passage through the bone. 

1 For interesting details of these symptoms the reader is referred to Hewett, in Holmes's 
System, vol. i. ; Von Bergmann, in Deutsche Chirurgie, Lief. 30, and Roswell Park. 



142 FRACTURES. 

Paralysis of other cranial nerves is occasionally observed, the result 
of direct injury of the nerve or of pressure upon it by extra vasated 
blood ; the facial is the one most frequently affected, then the abdu- 
cens. Paralysis of the limbs is caused by intracranial hemorrhage. 
Slowing of the pulse and irregularity of the respiration indicate hem- 
orrhage in the medulla. 

Fissured fractures of the vault are sometimes recognizable by a differ- 
ence in the level of the fr\vo sides and even in rare cases by the inde- 
pendent mobility of the two parts of the cranium. Auscultatory 
percussion has been alleged to be a means of recognition of a fissure, 
but I have found it wholly untrustworthy. The general symptoms are 
the same as when the fracture occupies the base and are dependent upon 
similar lesions of the brain. 

Emphysema of the scalp is a rare symptom and is due to the escape 
of air into it after fracture opening the mastoid, frontal, or ethmoid 
sinuses. 

The treatment of these fractures is medicinal and expectant : absolute 
quiet, light diet, laxatives, and cold to the head if indicated by rest- 
lessness, headache, or other symptoms of cerebral irritation. In frac- 
tures of the base with bleeding from the ear a light plug of iodoform 
gauze may be placed in the external meatus, but more active measures 
to disinfect this region seem to me wholly uncalled for in view of the 
fact that a route for infection from the mouth through the Eustachian 
tube remains and cannot be protected. 

Gushing l has reported excellent results in cases of bursting fracture 
with symptoms of compression from the " subtemporal decompressive 
operation;" 13 recoveries out of 15 cases. His incision runs from 
a point about midway between the edge of the orbit and the top of the 
ear upward and backward. The fibres of the temporal muscle are 
drawn widely apart, a disc four centimeters in diameter removed from 
the temporal bone, and the dura opened. Drainage is maintained for 
two days. 

I do not think it should be adopted as a routine treatment. Some 
cases are plainly hopeless from the beginning; others — 35 per cent, in 
my statistics — recover, generally without having shown alarming symp- 
toms at any time ; others, in an intermediate class, those which without 
evidence of a probably fatal injury at the beginning, do not improve 
but instead grow worse, may be proper subjects for decompression. 

When the fracture involves the vault and is compound the wound 
should be thoroughly cleansed, and to this end it is proper to chisel 
away the sides of the fissure, but I do not think it judicious to enlarge 
the wound in the scalp in order to follow up the fissure and treat it 
thus throughout its entire length. The interference is solely for disin- 
fection, and in fresh cases we may be confident that infection has not 
passed much beyond the limits of the external wound. Depression of 
one side of a fissure of the vault is not a justification for making an 
incision through the unbroken skin. 

1 Cushing: Annals of Surg., May, 1908, p. 641. 



FRACTURES OF THE SKULL. 143 

The same principles apply to the treatment of the intermediary 
group — extensive comminuted fractures with marked general cerebral 
symptoms. The important lesion is that of the brain, and it is not 
probable that good can be got by removal of fragments or relief of 
depression that will compensate for the risk incurred in dividing the 
unbroken scalp. Possibly the relief of tension by draining away the 
exudate through an incision may be an important advantage, but this 
has not been demonstrated. If the fracture is compound the wound 
must be cleaned and protected, and advantage may be taken of it to 
do whatever the condition of the bone requires, but this cannot be 
expected to have any important influence upon the progress and out- 
come of the injury. 

Certain exceptional forms of injury require separate description. 

Possible Fracture of the Internal Table. 

When the skull has been contused (compound) by a blow of the 
kind known sometimes to produce fracture of the internal table, such 
as a glancing bullet or a sharp blow by some small object, there can be 
no serious objection to trephining in order to insure cleanliness and 
determine the condition of the internal table, if care is taken not to 
open the dura ; and even when the skin is not broken, if well-marked 
symptoms of localized cerebral injury are present, a similar interference 
would, I think, be justifiable as an attempt to relieve a local and 
limited injury. But, I repeat, the known instances of fracture of the 
internal table alone are very few, and almost ail of them compound 
and fatal by infection through the scalp wound. If it is claimed that 
there are many simple (not compound) ones which pass unrecognized 
because the patient recovers, it must be added that that then is proof 
that an operation is not always necessary. The diagnosis of probable 
fracture of the internal table has been not infrequently made for no 
better reason than that no other could be positively made. Such mis- 
takes would be less frequent and officious treatment would be rarer if 
the fact was fully appreciated that early general cerebral symptoms 
mean generalized cerebral lesions, and that such cannot be relieved by 
local measures. For the latter there must be local indications. 

Rupture of the Middle Meningeal Artery. 

Rupture of the middle meningeal artery or of one of its branches by 
a fracture crossing its course, or even without fracture, is a not infre- 
quent injury of great importance and requiring immediate operative 
relief. As the vessel lies in a groove on the inner surface of the bone 
and is covered by the 'dura, the hemorrhage commonly takes place 
between the dura and the bone, stripping up the former sometimes for 
a considerable distance and causing symptoms of local and sometimes 
of general compression. Usually there is an interval, half an hour to 
three hours (occasionally very much longer, even eight days in one of 
Konig's cases and four and nine days respectively in two of mine), be- 
tween the blow and the development of the symptoms, an interval 



144 FRACTURES. 

during which the patient may seem entirely well, but which in other 
cases may be masked by the symptoms of cerebral injury occasioned by 
the primary violence ; the recognition in the latter case must then come 
through the steady increase in the symptoms and frequently the limited 
paralyses caused by pressure upon portions of the motor area. The 
pulse becomes slow (pulse of pressure), and the pupils unequal, that on 
the side of the injury being usually dilated. The paralyses, of course, 
are on the opposite side of the body ; if limited they indicate a hemor- 
rhage between the dura and the bone ; if diffuse, a hemorrhage into the 
arachnoid space. 

Left to itself the injury terminates fatally in the great majority of 
cases. Relief must be given by removal of the extra vasated blood 
and arrest of the bleeding. The difficulty may be to determine the 
point at which the trephine is to be applied to meet the indications; the 
guides thereto are furnished by external evidences of injury, the seat 
of the fracture, the situation of the centres corresponding to the paral- 
yses, the anatomical relations of the artery, and the relative frequency 
of hemorrhage at different points. The artery runs from the foramen 
spinosum across the middle fossa and upward along the greater wing 
of the sphenoid and there divides into two branches. The most fre- 
quent seat of rupture and hemorrhage corresponds to the lower anterior 
portion of the parietal bone (anterior branch of the artery) ; the next, 
but much less frequent, corresponds to the lower posterior portion of the 
parietal and the adjoining portion of the occipital (posterior branch). 

The size of the extravasation varies greatly ; I have seen one of less 
than an ounce directly above the ear in which the symptoms — stupor 
and limited paralysis — were well marked and which was cured by 
operation. 

If the exact position of the extravasation cannot be determined and 
if no indication is furnished by a line of fracture or paralysis, an open- 
ing made near the point where the frontal, parietal, and temporal bones 
meet, say two finger-breadths above the zygoma and an inch behind 
the external angular process of the frontal, will expose the most fre- 
quent seat and also the anterior branches of the artery. An opening 
about three inches directly behind this will expose the posterior region. 

The opening should be made with the trephine or by removing a 
broken fragment, and if the extravasation is not at once encountered 
the dura should be carefully separated from the bone in different direc- 
tions in search of it. When found the blood should be picked or 
washed out if clotted, and bleeding points should be secured if possi- 
ble, or, failing that, the wound should be packed in their neighborhood. 
The artery is often difficult to secure, especially when its point of rup- 
ture is not within the opening made by the trephine. Temporary 
pressure with the finger, an artery clamp, or even a pad of gauze has 
been successfully employed. In all my own cases the bleeding has 
stopped spontaneously before the removal of the clot. 



FRACTURES OF THE SKULL. 145 

Perforating Fractures of the Base through the Orbit. 

Perforating fractures of the base through the orbit are extremely grave 
and rarely accessible to treatment, the important lesions being usually 
that of the brain. In the extent of these lesions and their consequences 
the variations are very great. I have seen the breech-piece of a shot 
gun, about six inches long, driven into the brain through the nose and 
orbit and carried there, unrecognized, for more than two months, the 
patient recovering sufficiently to take a railway trip to the city in 
order to have the deformity of his face relieved; and in another a 
single birdshot which entered just above the tendo oculi and passed 
through the lower part of the frontal lobe directly back nearly to the 
Sylvian fissure caused death in a week without any evidence of inflam- 
mation and with only a minute intracranial hemorrhage. Sometimes 
an important feature is the wounding of the cavernous sinus or of a 
large artery. Another, and frequent one, is the infection of the deeper 
portion of the Mvound by the vulnerant body even if the superficial 
portion of the wound is small and heals kindly. The common cause 
is the passage of a small body — a bullet, cane, pencil — through or even 
between the eyelids. I have seen two cases in which a slender stick 
(the end of an umbrella in one) had thus penetrated and had broken 
off; both patients died, one after removal to another hospital and opera- 
tion there by the large omega-flap to expose the base of the brain, pro- 
fuse venous bleeding which could not be arrested was encountered and 
the patient died shortly after removal from the table. 

Similar wounds through the nose and mouth are even more exposed 
to infection. 

Summary. 

The principles of treatment may be thus summarized : Danger to life 
and function comes mainly from generalized contusion of the brain, 
large or small intracranial hemorrhages, and intracranial infection 
through an open wound; the fracture itself, as such, even when asso- 
ciated with depression, is rarely a factor in the fatal result. 

Against generalized cerebral injury the only treatment is medical — 
rest, sedatives, laxatives, cold to the head, unless experience should con- 
firm the value of Cushing's decompression. Against infection we have 
prevention and disinfection ; after it is fairly established disinfection 
and drainage have a restricted availability. Consequently, fractures 
of the base and fissured fractures of the vault not compound do not 
require operation. When compound, the wound may be enlarged suf- 
ficiently to permit disinfection of the area already exposed to infec- 
tion; and for the purpose of this disinfection a fissure may be enlarged, 
but this enlargement should not be carried much beyond the limits o^ 
the original wound. 

Depression of a portion of the skull below its normal level is not a 
condition which always needs to be corrected. The associated condi- 
10 



146 FRACTURES. 

tions which indicate its correction are limited paralyses or localized irri- 
tation due to pressure of the depressed portion upon the underlying 
portion of the brain. Conditions which justify its correction are an 
associated wound of the scalp and, in simple fractures with a well- 
defined small area of depression, the absence of symptoms of general- 
ized injury of the brain and consequently of fissures radiating from the 
depressed area which would favor the extension of infection if it should 
occur in the wound made for the relief of the depression. 

Epidural or subdural hemorrhage (rupture of the middle meningeal 
artery) requires operation for the removal of the extravasated blood 
and the arrest of hemorrhage. 

A monoplegia promptly following a blow upon the head is an indi- 
cation for the application of the trephine over the corresponding cor- 
tical centre, with the expectation of thereby removing a clot or a 
fragment which is making pressure on that portion of the brain. 

Late functional cerebral disturbances (epilepsy, etc.) appear to be 
so much more closely connected with injury of the brain and meninges 
which cannot be corrected by a primary operation than with traumatic 
irregularities on the inner surface of the skull which can be thus cor- 
rected, that an early operation for their prevention is not indicated. 

Severe meningeal or cortical inflammation, not connected with an 
external wound, is so rare that operation for its prevention is not indi- 
cated, and is, indeed, more likely to produce it than to prevent it. 



CHAPTER XL 

FRACTURES OF THE VERTEBRA. 

Fractures of the vertebrae have this in common with fractures of 
the skull, that most of their importance depends upon the associated 
injury of the nerve-centres and trunks contained within their canal, 
but they have in addition the importance due to the function of the 
spine as a support for the head and trunk. Upon the integrity of this 
support depend not only the power of locomotion, but also grace of 
carriage and dexterity in the use of the limbs. 

The spinal cord, occupying the centre of the vertebral column, is 
efficiently protected against any external violence that is not sufficient 
to break the bones that constitute the latter, or the ligaments and mus- 
cles that bind those bones together ; and the column itself is constituted 
in a manner that combines elasticity and mobility with the necessary 
firmness and rigidity. The bodies of the vertebrae, increasing in size 
from above downward in correspondence with the variations in the 
weight and strain which the different ones are called upon to bear, are 
composed of spongy tissue and separated from each other by the elastic 
intervertebral cartilages, and prevented from changing their positions 
by the interlocking of the articular processes upon the sides. The 
general form of the column is that of a long slender cone with a double 
antero-posterior curve, and its component parts are strongly bound 
together by ligaments and muscles allowing a range of motion which, 
while small between each pair of vertebrae, is in the aggregate consid- 
erable. Mechanically, therefore, the spine is exposed to fracture by 
direct violence, like other bones, and by indirect violence through 
exaggeration or straightening of its normal curves. 

In the displacements following fracture the corresponding joints may 
be dislocated, and as in dislocation there may be associated fracture, and 
as the symptoms in the two forms of injury are in many respects the same, 
they are sometimes grouped as " fracture-dislocations " of the spine. 

Fractures of the vertebrae are relatively rare, 0.5 per cent, in my 
statistics (Chapter I.). Gurlt collected 270 cases, with 444 fractures, 
and found that fractures of the cervical aud dorsal vertebrae are about 
equally frequent, 178 and 184 respectively, while those of the lumbar 
vertebrae, 82, are much less common ; that the fatal cases of fracture 
of the cervical vertebrae are, however, considerably more numerous, 
actually and relatively, than those of the two other regions ; that the 
fifth and sixth cervical, the last dorsal, and the first lumbar are more 
frequently broken than any of the others; and that it is common in 
fractures of the cervical and dorsal regions for more than one vertebra 
to be broken at the same time. They are extremely rare in childhood 
and old age, and relatively infrequent in women. 

147 



148 



FRACTURES. 



The part most frequently fractured is the body of the vertebrae — 
that is, in about two-thirds of all cases, or in more than half of the 
fractures of the cervical vertebrae, in about seven-eighths of those of 
the dorsal vertebrae, and in about all those of the lumbar vertebrae. 
Or, in general terms, fractures of the bodies of the vertebrae begin at 
about the middle of the cervical region and increase in frequency down- 
ward. Simultaneous fracture of two or more vertebrae is common in 
the cervical and upper dorsal regions, less common in the lower dorsal, 
and rare in the lumbar region. Fracture of one or more of the ver- 
tebral processes either of the same or of adjoining vertebrae is common. 

Pathology. 

The fracture of the body of a vertebra may be complete or incom- 
plete ; the line of fracture may extend only partly through it or en- 
tirely across it, or it may be broken into several fragments, or com- 
pressed, or impacted. The line of fracture, if single, may be vertical, 
horizontal, or oblique in any direction ; the first being found almost 
exclusively in the cervical and upper dorsal regions, the two latter 
and multiple fractures occurring everywhere. The transverse and 
oblique fractures lie, as a rule, nearer the upper than the lower 



Fig. 58. 



Fig. 59. 





Transverse fracture of vertebra. 



Displacement of the vertebrae causing compression 
of the spinal cord. 



border of the bone, and may pass from the upper to the anterior sur- 
face, leaving the posterior and lower surfaces unbroken, and in these 
cases the upper fragment preserves its relations to the overlying ver- 
tebra and is displaced with it forward and downward, producing a 
change in the long axis of the spine characterized by an angle having 
its apex directed backward at the seat of fracture. This displacement 
narrows the antero-posterior diameter of the spinal canal and lacerates 



FRACTURES OF THE VERTEBRM. 



149 



Fig. 60. 



or compresses the spinal cord within it. If the line of fracture is 
oblique, and if fracture or dislocation of the articular processes is asso- 
ciated with it, the displacement is inclined to the corresponding side 
either directly or by rotation. 

Compression of the body of a vertebra is found either in combina- 
tion with comminuted fracture or alone, and involving one or several 
vertebra?. It is apparently caused by 
forcible forward flexion, in which either 
the posterior portions of the vertebra? 
must separate from each other or the 
anterior portions must approximate by 
condensation of the intervertebral disks 
or of the bone. 

The compression may be so extreme 
that the intervertebral disks above and 
below the affected vertebra are brought 
into contact with each other in front, 
the substance of the bone being partly 
compressed and partly forced out upon 
the sides or behind into the spinal canal 
(Figs. 61 and 62),eompressing the cord. 
With this compression may be associ- 
ated fracture or fissure of the body, and 
especially fracture of the processes of 
the same or the adjoining vertebra. 

anterior portion of the body may be produced by splintering of part 
of the bone or by impaction of one fragment into another lying above 




Compression of the last dorsal vertebra. 

The same shortening of the 



Fig. 61. 



Fig. 62. 





Fracture with compression of the third and fourth lumbar vertebra 1 



or below it. The intervertebral disk may be partly squeezed out, 
bringing with it a scale of bone from either or both vertebrae. 

Fracture of the vertebral arches, according to Gurlt, is found in about 
half the cases of fracture of the cervical vertebrae, and onlv in one- 



150 FRACTURES. 

seventh of those of the dorsal, and one-eighth of those of the lumbar. 1 
He attributes the frequency of this form of fracture in the cervical 
spine to the comparatively greater breadth and less height of the arch 
and to the absence of that protection which is furnished in the dorsal 
and lumbar regions by the larger and stronger spinous, transverse, and 
oblique processes. When the arch is broken on each side the interme- 
diate portion bearing the spinous process may be driven into the spinal 
canal and cause fatal laceration or compression of the cord. Gurlt's 
statistics contain six such cases, affecting the fifth, sixth, and seventh 
cervical vertebra?. 

The spinous processes are broken most frequently at those points 
where they are longest and thinnest, nearly one-fourth of the cases 
occurring in the cervical spine, more than half in the dorsal, and 
about one-eighth in the lumbar ; and often several adjoining ones 
are broken at the same time. In the dorsal region this fracture is 
usually found only in combination with fracture of the body of one 
of the vertebras above or below it. Isolated fracture of a spinous 
process may occur as the result of direct violence, or of muscular 
action, and the displacement is either directly downward or to one 
side. 

Fracture of the transverse or articular processes occurs in combina- 
tion with other fractures in about one-sixth of all cases, but is rare 
except in such combination. In the few instances in which it has 
occurred alone it was the result of gunshot injury. As a complication 
of other fractures the proportion of its occurrence for the transverse 
process is greatest in the cervical and next in the lumbar and dorsal 
regions ; for the articular processes it is greatest in the cervical and 
smallest in the lumbar. Fracture of a transverse process of a dorsal 
vertebra may lead to fracture of the rib which articulates with it, and 
fracture of the transverse process of a cervical vertebra may seriously 
injure the vessels contained in the vertebral canal. Fracture of an 
articular process exposes to dislocation of the vertebra with all its 
accompanying dangers. 

The ligaments which bind the different vertebras together are torn 
in fracture to an extent which varies with the severity of the injury 
and the degree of the displacement, and the intervertebral disks may 
be torn, displaced, or compressed. In rare cases the injury may be 
confined to the ligaments and disks — real dislocation or diastasis with- 
out fracture — although the distinction cannot be made during life. 

The spinal cord, the diameter of which is considerably less than that 
of the canal in which it lies, is suspended within the dura mater, which 
is itself loosely connected with the bones and separated from direct con- 
tact with them in most places by a rich venous plexus. The medul- 
lary portion of the cord ends at the first or second lumbar vertebra, and 
its lower portion is enveloped by the numerous nerve trunks which 
pass downward to form the cauda equina and the lumbar and sacral 
plexuses. The cord is injured directly only when the lumen of the 
canal is considerably encroached upon by the displacement of a frag- 

1 For cases of doubtful character in the lumbar vertebrae, see section on Course and Ter- 
minations. 



FRACTURES OF THE VERTEBRM 151 

ment or of a vertebra, but it can be compressed by extravasated blood 
or by inflammatory exudations, or torn by elongation. T have seen 
it so injured in fracture of both laminae of the sixth cervical without 
displacement, by anterior flexion of the neck, as to cause immediate 
paraplegia and death in a week. Occasionally the cord is penetrated 
by a sharp fragment, but usually the dura mater is untorn and the cord 
is crushed between the anterior portion of one fragment or vertebra, 
usually the lower, and the posterior portion of another, usually the 
upper. This crushing presents all degrees, from a slight flattening to 
complete disorganization, and apparently the medullary portion is more 
easily and permanently injured and destroyed than the nerve-fibres in 
the columns beside it. 

Hemorrhage, Haematomyelia. Hemorrhage, without division of the 
cord, may be extra- or intra-dural, or within the substance of the cord 
(haematomyelia). Hemorrhage outside the cord spreads upward and 
downward within the canal and produces changes and symptoms by 
pressure upon the cord. 

Haematomyelia is apparently caused by forcible elongation of the 
cord in hyperflexion or extension of the column, with or without recog- 
nizable lesion of the ligaments or bones; it is seen almost exclusively 
in the lower cervical and upper dorsal region, but sometimes near the 
junction of the lower dorsal and lumbar regions. The condition, first 
pointed out by Thorburn and Minor, of Moscow, about 1890, has 
been recently studied in detail by Bailey 1 and Bolton. 2 The hemor- 
rhage takes place in the gray matter of the cord and may be very 
closely limited to it, spreading upward and downward in it through 
two, three, or even more segments. If the lesion is more severe the 
hemorrhage may extend into the white columns as a clot, or appear 
there as punctate extravasations. If the patient survives the blood 
is absorbed, leaving cavities within the cord which contain a viscid 
liquid and tend toward obliteration by formation of connective tissue. 
The elements of the gray matter, cells and fibres, which are injured by 
the hemorrhage appear to be incapable of repair with restoration of 
function, but pressure-effects upon adjoining parts may be, and ap- 
parently frequently are, recovered from. Consequently, the recogni- 
tion of the condition is of great importance in prognosis and in deter- 
ring from active surgical interference. Apparently most of the cases 
of injury to the neck which recover after having presented symptoms 
of severe injury to the cord are cases of haematomyelia. In a notable 
number of them the injury has been caused by diving into shallow 
water, the head being thrown forcibly back to avoid contact with the 
bottom. 

Etiology. 

The immediate causes are muscular action and external violence. 
The former is very rare and acts either by a direct pull of the muscle 
upon the process to which it is attached or by the momentum given 
by the head in sudden dorsal flexion of the neck or rotation of the 
head. The most frequent examples of the latter (producing either 

1 Bailey: Med. Record, Nov. 19, 1898. - Bolton: Annuls of Surg., An-.. 1899. 



152 FRACTURES. 

fracture or dislocation of the cervical spine) have been in cases in 
which the patient has dived into shallow water and has thrown his 
head backward to escape contact with the bottom. 

The commonest cause is the forcible bending of the spine in a fall 
or, less frequently, by the weight of a falling object or by the com- 
pression of the body in a narrow space, as in driving under an archway 
(indirect fracture). The relative frequency of the injury at> the lower 
part of the cervical spine and at the junction of the dorsal and lumbar 
segment seems to be associated with the fact that at these points the 
more flexible and the more rigid portions of the column meet, such 
meeting points being specially liable to break in all combinations of 
flexible and rigid bodies. 

Fractures by direct violence are infrequent and are usually found in 
the posterior portion of the vertebra. 

Symptoms and Diagnosis. 

(See also Dislocations of the Vertebrae.) 

The symptoms of fracture of the spine vary with the position and the 
portion of the vertebra involved, and therefore need a separate and 
detailed consideration in connection with the different groups of frac- 
tures. But there are certain general symptoms common to most which 
may first be mentioned. After the first shock of the injury, which usually 
passes off without permanent impairment of the intelligence, the patient 
complains of a localized pain at the seat of fracture increased by manip- 
ulation or movements. There is usually a recognizable deformity con- 
sisting of a change in the direction of the spine, a more or less marked 
angular projection backward with or without swelling of the surround- 
ing soft parts ; crepitus can sometimes be made out by the surgeon, but 
more commonly it is appreciable, if at all, only by the patient himself 
when his body is moved. The most important and constant symptom 
is paralysis, motor and sensory, more or less complete, of the limbs and 
the portion of the body lying below the fracture. If complete its 
upper limit is usually sharply defined by a line crossing the trunk and 
corresponding to the adjoining limits of the regions supplied by the 
nerves that leave the column immediately above and below the point 
at which the cord has been injured. The consequences of this paralysis, 
if it involves the abdominal muscles, bladder, and rectum, are reten- 
tion of urine and feces, followed by incontinence of one or both, by 
alkaline fermentation of the former, and cystitis. Respiratory diffi- 
culties, sometimes severe enough to cause death, appear when the frac- 
ture involves the upper portion of the spine, the result of the paralysis 
either of the abdominal muscles or of the diaphragm, or of vasomotor 
injury. There is also a great tendency to sloughing at all points of 
pressure within the paralyzed region, especially over the sacrum and 
trochanters and along the back. The sloughs appear promptly, some- 
times within two or three days, are usually symmetrical, and often 
hasten death even if they are not its immediate cause. 

Paralysis is, of course, only a symptom of injury to the cord and 



FRACTURES OF THE VERTEBRJE. 153 

may follow violence that has caused neither fracture or dislocation. 
Thus, a diastasis of two vertebrae, followed by immediate return to 
their normal relations, may cause hemorrhage into the canal or may 
even injure the cord by elongation and thus cause paralysis. A paral- 
ysis appearing shortly after an injury, and increasing, generally indi- 
cates hemorrhage into the canal, but I have seen it caused by displace- 
ment, with pressure, occurring during the transfer of the patient to 
hospital, the condition being shown by autopsy. 

Extension of paralysis indicates hemorrhage or an ascending mye- 
litis. 

In hsematomyelia there is immediate motor paralysis (usually para- 
plegia, but occasionally hemiplegia, when only one gray column is 
affected) which is transient except for those muscles whose spinal 
nuclei in the gray matter have been destroyed by the hemorrhage. 
Thus, when the lesion is situated in the lower cervical region the paral- 
ysis of the lower limbs and the sphincters promptly disappears, but 
that of the muscles of the forearm and hand remains in part. The 
interference with sensation is constant and characteristic : there is loss 
of sensibility to heat and cold (thermo-anaesthesia) and usually insensi- 
bility to pain (analgesia) also, but tactile sensibility is not aifected. 
Bailey says the distribution of these disturbances is the same as that 
of the anaesthesia of a corresponding transverse lesion of the cord, but 
that it may present the Brown-Sequard type, namely, motor paralysis 
of one arm and leg with loss of pain-sense and temperature-sense in 
the arm and leg of the opposite side. The tendency is toward 
improvement, and sometimes recovery is complete. The reflexes are at 
first lost, then slowly regained. 

In complete transverse injury there is permanent complete paraplegia 
and loss of all kinds of sensation and of the reflexes. 

In incomplete transverse injury there is irregular paraplegia, the 
sensibility to pain, touch, and temperature may persist or be regained 
in limited areas below the lesion, and the reflexes return and become 
exaggerated. 

Priapism, more or less complete, was observed, according to Gurlt, 
in 31 of 96 cases of fracture of the cervical and two upper dorsal ver- 
tebrae, 16 times in 133 cases of fracture between the third dorsal and 
second lumbar vertebrae, and never in fracture below the latter. It 
appears promptly, usually on the first or second day, and seldom lasts 
longer than a fortnight. Notwithstanding the insensitiveness of the 
penis it may be caused or increased by the use of the catheter. On the 
other hand, in one case the erect organ became relaxed as soon as the 
catheter had passed over half the length of the urethra. Ejaculations 
are very exceptional, there being only four instances in Gurlt's collec- 
tion, all of them in cases of fracture of the cervical spine. 

Fracture of Atlas and Axis. 

The intimate relations existing between these two bones and the 
medulla oblongata, and their position above the roots of the phrenic 
nerve as well as above those of the other nerves supplying other 



154 



FRACTURES. 



Fig 



muscles which aid in respiration, make their injury especially danger- 
ous, and have probably led to the generally received opinion that their 
fracture is, as a rule, immediately fatal. Gnrlt's cases show, however, 
that this opinion is not correct, for in the eleven in which the nature 
of the injury was demonstrated by the autopsy, death occurred imme- 
diately in only two, and in only two others within an hour after the 
injury was received. In the other cases the patients survived for a 
considerable length of time, thirteen days in one, although some of 
them at the last died suddenly, apparently by displacement of the ver- 
tebrae due to incautious movements. The fractures were all caused by 
external violence, sometimes slight, as a fall from the bed while trying 
to reach down to the floor. 

The parts broken in ten of these eleven cases were : the odontoid 
process alone once ; the odontoid process and posterior arch of the atlas 

three times ; the posterior arches of the 
atlas and axis three times ; the poste- 
rior arch of the axis alone once ; the 
spinous process of the axis twice. In 
six of the cases there was associated 
fracture of other cervical or dorsal ver- 
tebrae, and in no case was the trans- 
verse ligament torn. Figure 63, taken 
from a specimen in the museum at 
Braunschweig, shows a fracture of the 
superior articular surface of the axis. 
The patient was twenty-four years old, 
and died in a few hours after falling 
out of a wagon upon his head. 

The symptoms of this fracture are 
so variable and so indefinite and have 
so much in common with simple dis- 
location of one bone upon the other, 
or of the atlas upon the skull, that the diagnosis is extremely diffi- 
cult. On the one hand, the patient may die instantly ; on the other, 
he may survive a longer or shorter time, either completely paralyzed 
or presenting no important symptoms, and then die suddenly by dis- 
placement of the fragments or gradually by extension of the symp- 
toms, or in consequence of other injuries, or, if the diagnosis in some 
such cases may be accepted, may even get well. The symptoms of 
local pain and stiffness of the neck are too indefinite to be of any ser- 
vice, and paralytic symptoms may be entirely absent, as in Gurlt's 
second case, where the patient walked for two hours after the accident to 
reach home and developed no paralysis until the following day. Death 
took place suddenly on the eighth day, and the autopsy showed fracture 
of both arches of the atlas and of the odontoid process. 

The symptoms in those of Gurlt's eleven cases which survived long 
enough to present any, or in which any are recorded, were complete 
paralysis of all the parts below the fracture in some, partial paralysis 
in others, only a slight diminution of sensibility in the left arm in one, 
pain in the neck or occiput in six, rigidity of the neck in most, absence 




Fracture through the superior articular 
surfaces of the axis. (Gurlt.) 



FRACTURES OF THE VERTEBRJE. 155 

of recognizable deformity in all, distinct cripitus in one, and falling 
forward of the head upon the breast in one. All of these symptoms 
— pain, rigidity, paralysis, sudden death — may be the result of dislo- 
cation as well as of fracture, and, as dislocation has in addition no 
general or local characteristic symptoms which serve to distinguish it, 
the differential diagnosis must usually remain in doubt. 

Fractures of the Lower Five Cervical and First Two Dorsal Vertebrae. 

The special characteristics of fractures of this region are due to the 
inclusion within it of the roots of the phrenic nerve and brachial plexus. 
The former passes out through the intervertebral foramen between the 
third and fourth cervical vertebrae, either coming from the fourth cer- 
vical pair alone, or receiving branches also from the third and fifth 
pairs. The brachial plexus is formed by the four lower cervical and 
the first dorsal pairs. Consequently, if the fracture is accompanied by 
displacement of the fragments and injury to the spinal cord, paralysis 
of the upper limbs also is caused, and if the fracture is high enough 
in the region to involve the phrenic nerve directly or by extension 
death follows promptly, preceded by the respiratory symptoms peculiar 
to lesion of this nerve. 

Here, too, as after fracture of the altas and axis, are found cases in 
which the patients present only symptoms of paralysis for a longer or 
shorter time, and then die suddenly of asphyxia in consequence of some 
accidental or intentional movement of the head, which probably causes 
compression of the phrenic nerves by displacement of the fragments. 

The paralysis in fractures of the portion of this region below the 
fourth cervical vertebra shows many variations. From the relations 
of this part to the brachial plexus it might be expected that paralysis 
of the upper limbs would be a constant symptom, excluding those cases 
in which there is no displacement, but Gurlt's tables show this paral- 
ysis to have been present in less than one-fourth of the cases, that in 
the majority complete paralysis of the lower portion of the body 
extended upward at first only to the middle of the breast, the second 
rib, rarely to the neck, clavicle, or shoulders, and sometimes not even 
to the umbilicus, although it often advanced to a higher point later in 
the progress of the case. Paralytic symptoms appeared in the arms, 
as a rule, either later on the day of the accident or on the following 
day. The paralysis may be complete in one arm and partial or absent 
in the other ; it may be complete of motion and incomplete of sensa- 
tion, or the reverse ; it may be limited to the arm or to the forearm : 
or the injury to the nerves may be evidenced by abnormal sensations, 
such as numbness or prickling in the limb. Probably incompleteness 
of paralysis is due in most cases to the conservation of some of the 
nerve fibres, although the medullary position of the cord is completely 
destroyed by crushing. Hyperesthesia affecting the whole or part 
of the limb is occasionally observed, and is sometimes associated with 
sharp, lancinating, continuous or intermittent pain, which may be 
spontaneous or may be excited or increased by the slightest touch of 
the surface. Tonic or clonic spasms are seen somewhat more 



156 FRACTURES. 

frequently than hyperesthesia, sometimes limited to the arms alone, 
sometimes involving other muscles also. 

An important consequence of the paralysis is the change in the 
respiratory act due to the withdrawal of the aid of the accessory mus- 
cles when the phrenic nerve is uninjured. As a consequence of the 
paralysis of the intercostal and abdominal muscles, inspiration is 
effected by the diaphragm alone, and expiration by the weight of the 
abdominal walls and viscera which sink back to the positions from 
which they have been displaced by the contraction of the diaphragm. 
As the expiration is thus purely passive the patient cannot sneeze or 
cough strongly, and as he is thus prevented from clearing his lungs 
of the mucus which collects in them it gives rise to plentiful moist 
rales. If the phrenic nerve shares in the injury the diaphragm acts 
very slowly, perhaps not oftener than twice or thrice in the minute, 
the breathing is noisy or sighing, and the shoulders may be slightly 
raised at each inspiration. Sometimes a change in the position 
increases or diminishes the difficulty by modifying the pressure upon 
the cord. A noticeable slowing of the pulse accompanies this defec- 
tive respiration. 

The local symptoms are usually few and obscure, often nothing 
more than the pain that is felt at the seat of fracture and is increased 
by pressure or motion. Sometimes there are positive objective signs: 
an abnormal projection or depression of one or more spinous pro- 
cesses, an irregularity on the posterior wall of the pharynx produced 
by the displaced body of a vertebra, lateral displacement of one or 
more spinous processes, irregularity in the line of the transverse pro- 
cesses, and possibly crepitus or abnormal mobility. 

The position and mobility of the head vary greatly in different 
cases. In some cases they show nothing abnormal, in others the head 
can be moved freely to either side, but not forward or backward, and 
in others it is held firmly fixed in some one position and any attempt 
to change that position causes pain. This rigidity is due not to change 
in the relations of the articular surfaces, but to the involuntary 
spasmodic contraction of the muscles which is nature's method of pre- 
venting the infliction of pain by movement of the parts. 

It is to be borne in mind that, as stated above, this is the region in 
which traumatic hsematomyelia almost exclusively occurs, and that 
examination of the sensibility to heat, cold, and pain should be made 
whenever, in connection with more or less motor paralysis, there is 
preservation of the touch-sense. 

It is apparent that the diagnosis of fracture of this region may be 
difficult or impossible. The most that can be done in many cases is to 
recognize approximately the seat of the injury. Thus, paralysis or 
symptoms of irritation in the arms, even if they first appear after 
some delay, indicate a lesion above the second dorsal vertebra, although 
in a few exceptional cases this symptom has existed when the injury 
was lower on the spine, and was then due probably to an associated 
brain lesion or a large collection of blood within the spinal canal. If 
all local and functional signs are absent the diagnosis is, of course, 
impossible, and the real nature of the injury may be entirely over- 



FRACTURES OF THE VERTEBRAE. 157 

looked uotil the progress of the inflammation or a chanee displace- 
ment of the fragments brings it to light. 

The prognosis is extremely unfavorable. Gurlt's tables contain 96 
fatal cases, and only 8 which ended in recovery, and in one of these 
the symptoms reappeared after a fall and the patient died in conse- 
quence. In one-third of the cases death took place within the first 
four days; in 20 between the fifth and twelfth; in 11 between the 
thirteenth and thirty-sixth ; and in one case the patient survived five 
months. I have known two cases in which life was prolonged more 
than a year, without change in the paralysis. In hsematomyelia the 
prognosis is much more favorable. 

Fractures of the Lower Ten Dorsal and First Two Lumbar Vertebrae. 

This region includes another point at which fractures are very 
common, the lower dorsal and the first lumbar vertebrae. Its position 
below the origin of the brachial plexus prevents the involvement of 
the arms in the paralysis except in rare cases where this unusual exten- 
sion is due apparently to the spread of inflammatory softening of the 
cord or to the pressure of extravasated blood. Paralysis of the lower 
limbs, the bladder, and rectum, which is one of the common results of 
fracture in this division as well as in the higher ones, may be entirely 
absent at the beginning, especially after fracture of the second lumbar 
vertebra, or, more frequently, may be incomplete, the motor paralysis 
being, as a rule, more marked than the paralysis of sensation. The 
latter may extend as high as the lower part of the breast, or may stop 
at the groin, and sometimes even does not reach above the lower part 
of the thigh. A common result of the paralysis is the immediate 
retention of urine and feces, followed, as before mentioned, by incon- 
tinence and by alkaline decomposition of the urine and cystitis. This 
incontinence persists until death takes place or improvement begins. 
The disturbance in the function of the bowels aided by the flaccid ity 
of the abdominal muscles produces tympanites, which makes its 
appearance usually within a day or two and may be sufficiently marked 
to interfere with respiration by crowding the diaphragm upward and 
opposing its contraction. In other cases, even of apparently severe 
injury to the body of a vertebra, there may be an entire absence of 
paralytic symptoms and even of those of meningeal irritation. 

The diagnosis is aided by objective symptoms, which are more 
marked and distinctive than those found after fractures of the upper 
portion of the column, because as the fracture in the great majority of 
the cases involves the body of the vertebra, and is comminuted or 
accompanied by displacement, there is usually a recognizable deformity 
consisting in an angular change in the long axis of the spine, with 
projection of the spinous process of the broken vertebra or of the one 
immediately above it. This change in the position of the spinous 
process is sometimes so marked that the finger can be pressed deeply 
in between it and the next lower one. 

The possibility of traumatic hsematomyelia in the lower part oi % this 
region must not be overlooked. 



158 FRACTURES. 

The prognosis, as regards both life and recovery of function, is more 
favorable than after fracture at a higher point. 

Fractures of the Lower Three Lumbar Vertebrae. 

Fractures of this portion of the spine appear to be exceedingly 
rare. 1 The absence of paralytic symptoms and recognizable displace- 
ment would make the diagnosis during life practically impossible. 

As this portion of the spinal canal contains only nerve trunks, which 
are better fitted by their texture and comparative independence of each 
other to resist or escape damaging pressure by displaced fragments than 
the spinal cord itself is, paralysis may be absent even when the dis- 
placement is marked ; in some cases it has been Complete, both of 
motion and sensation, over the limbs and abdomen. The patient may, 
however, be unable to walk in consequence of the loss of support occa- 
sioned by the fracture, or he may walk only feebly and in a bent pos- 
ture. But if union takes place, even if the deformity persists, he may 
be as strong and capable as before. In short, the prognosis is favor- 
able as regards both life and function. 

Course and Terminations. 

The course and terminations of fracture of the spine, with their 
many variations as regards both the life and principal functions of 
the patient, have been indicated in the preceding section ; we have 
now to consider the changes effected in the broken bone by the process 
of repair, and to describe some of the later symptoms with more 
detail. 

Repair takes place by a callus which may remain fibrous, but is 
usually bony and possesses ample solidity notwithstanding the com- 
mon persistence of displacement. In fractures that have been healed for 
a long time is found the same absorption of projecting angles and sur- 
faces which has been noticed in connection with other fractures, and 
this absorption is especially marked in the bodies of the vertebrae. 
If several adjoining vertebrae are broken at the same time the inter- 
vertebral disks disappear in part by absorption, and the remaining 
portions undergo partial or complete ossification, uniting structurally 
with the vertebrae, and thus forming a more or less extensive, rigid, 
bony mass. The length of time required for consolidation appears to 
be greater than for that of other spongy bones. 

A number of instances of complete pseudarthrosis have been re- 
corded and their origin differently interpreted. Gurlt collected 21 such 
cases : 1 of the odontoid process, 4 of the spinous processes of the 
cervical, dorsal, and lumbar vertebrae, and of the sacrum, 3 of the 
transverse processes of lumbar vertebrae, 11 of the arches of lumbar 
vertebrae, and 2 of the side of the upper false vertebra of the sacrum. 
Meckel considered the 11 cases involving the arches of lumbar ver- 

1 If the specimens of supposed ununited fracture of the arch of these bones, which have 
been found upon the dissecting-table, in museums, and in old Indian graves, are accepted 
as such, they raise the question whether similar fractures are not more common than has 
been supposed, and whether they may not be present, without displacement, in some of 
the severe, so-called strains of this region. 



FRACTURES OF THE VERTEBRJE. 159 

tebrae as instances of arrest of development, comparing them with the 
vertebrae of some reptiles, which consist normally of a separate body 
and arch, and in which many of the processes also remain ununited. 
Otto opposed this view, because the position of the false joint does not 
correspond to that of the line between the diaphysis and epiphysis, and 
Wyman, 1 who reported eleven additional cases and did not know of 
these earlier ones, held the same opinion for the same reason. Gurlt 
accepted Meckel's opinion concerning the arches of the lumbar verte- 
brae, and claims that it is probably true also of the other cases. His 
reasons are that there is no trace of injury to other parts, and that it 
is known that fracture limited to a vertebral arch, a spinous, or a trans- 
verse process is exceedingly rare ; that most of the cases relate to the 
lowest lumbar vertebrae, fractures of which, of any kind, are rare, and 
in the case of the fifth unknown ; and that the identity of the position 
of the joint in all corresponding cases, and its perfect structure, point 
strongly to an arrest of development, and are incompatible with a frac- 
ture by external violence. Shepherd 2 reports another of the fifth 
lumbar vertebra found in the dissecting-room. 

Suppuration at the seat of fracture, which is very rare in other bones, 
seems to be more common after simple fracture of the spine, and is 
attributed by Gurlt to the greater complexity of the anatomical condi- 
tions and to the less perfect immobility maintained during the progress 
of the case. His statistics contain eight cases in which, excluding 
instances of suppurative meningitis, more or less pus was found after 
death at the seat of fracture. 

As to the recovery of the cord after injury, with restoration of func- 
tion, nothing definite is known beyond the fact that a number of autop- 
sies made at various periods after injury have shown the cord more or 
less completely divided, or reduced to pulp at the compressed part, or 
replaced by fibrous tissue. There is nothing to prove that a disinte- 
grated portion can be restored, or that divided cords can be reunited, 
and it is not easy to see how proof of such a fact could be furnished 
except by experiment. In those cases in which paralysis has disap- 
peared after a time, it is impossible to know exactly what was the 
nature of the lesion of the cord that caused it, but probably most of 
them are cases of moderate haematomyelia. 

In one or two cases recently published, in which a partial division 
of the cord has been demonstrated by operation, partial recovery of 
function has followed. I doubt if this can be held to prove more than 
that nerve-fibres of the cord can reunite, with re-establishment of 
conduction. That destruction of the gray matter can be made good 
must still be deemed unproved, and unfortunately that destruction is 
the common lesion in fracture. 

The troubles created by paralysis of the bladder are very serious, 
and often hasten a fatal termination. They begin, usually promptly, 
with retention, which if not looked for by the surgeon may pass unno- 
ticed, since it gives the patient no pain, until the distention of the 
bladder has become so great that the urine begins to dribble away 

1 Wyman : Boston Medical ami Surgical Journal, August U, 1869, 

2 Shepherd : Montreal Medical Journal, June, 1892. 



160 FRACTURES. 

through the urethra. The symptoms aud usual consequences of the 
consequent cystitis are such as are commonly observed when the same 
affection is excited by other causes, and do not require a detailed de- 
scription here ; but in addition to these common ones there are occa- 
sionally observed others of great gravity, such as sloughing of the wall 
of the bladder, and pericystitis with formation of abscesses. 

Every effort should be made to delay the appearance of this compli- 
cation and to diminish its severity, and with this object the water must 
be regularly drawn as soon as the first signs of retention appear. It 
is usually sufficient to use the catheter twice a day ; it must be steril- 
ized and passed with even more than the usual precautions and gentle- 
ness because the patient's insensitiveness creates an additional risk of 
doing damage unwittingly to the urethral wall. After cystitis has 
appeared and the urine has become turbid, the bladder should be 
washed once or twice a day. Permanent drainage of the bladder 
through a perineal or suprapubic incision has been employed with 
advantage. 

Bed-sores appear promptly after any fracture that has caused para- 
plegia by a complete transverse lesion of the cord, but are absent in 
hsematomyelia. The skin at first becomes white, then mottled, and 
then sloughs, and the slough spreads peripherally and in depth. The 
commonest seat is the skin covering the convexity of the sacrum, then 
other prominent points upon the back and legs. The cause of this 
early sloughing has been thought to lie in injury to nerves or nerve 
centres presiding over the nutrition of the parts; but Mr. Shaw 1 
explains it by the pressure which is continued for a length of time 
and with an absence of interruption unknown except in connec- 
tion with paralysis. Not only is the patient unable to move, but he is 
insensitive to the prolonged pressure, and does not seek to change his 
position or to have it changed. He lies absolutely motionless in one 
settled position ; the pressure interrupts the circulation at certain 
points, and, if this interruption continues unrelieved, the part dies. 
The presence of urine or liquid feces may prove an additional source 
of irritation, as may also creases or irregularities in the bed-clothing, 
and lack of attention and scrupulous cleanliness. The rapid improve- 
ment which sometimes takes place in these sloughs, even when the 
paralysis remains complete, as soon as the consolidation of the fracture 
is sufficiently advanced to allow the patient to be readily moved, is 
corroboration of the opinion. Some cases which have recovered with 
permanent paraplegia have shown, on the other hand, a very marked 
tendency to the formation of sloughs on slight provocation, and in one 
case 2 the tarsal bones of both feet became necrotic. 

In those cases in which the patients survive the injury and its more 
immediate consequences, it is sometimes found that the paralysis grad- 
ually diminishes and may even disappear entirely. The beginning of 
the improvement is sometimes marked by the appearance of sharp 
darting pains in the limbs and of muscular twitchings excited by slight 
causes, such as pinching or touching the skin ; then the power of vol- 

1 Shaw : Holmes's System of Surgery, Am. ed., vol. i. p. 810. 
2 Courier Medical, November 11, 1882. 



FRACTURES OF THE VERTEBRA. 161 

untary motion returns, first in one muscle, then in another. Sensation 
returns usually before motion ; the bladder is found to be again able to 
retain a certain quantity of urine and to expel it with some force ; and 
a similar improvement is presented by the rectum, although, as a rule, 
even in the best cases, the functions of the rectum and bladder remain 
partially and permanently disabled. The improvement in the paralysis 
may be very slight, or it may go on to complete restoration of function, 
or it may be arrested at any intermediate stage. Cases have been 
referred to in which a permanent deformity existed, but the functions 
of the body and limbs were in no manner disturbed by it. Finally, 
after a short period of apparent recovery, symptoms of progressive 
degeneration of the cord or of pachymeningitis may appear. 

Treatment. 

The indications, as in other fractures, are to reduce displacement 
and to immobilize until repair shall have taken place, but the limita- 
tions which exist in so many other fractures exist here to an even 
greater extent because of the uncertainty as to the character of the 
displacement, the difficulty in modifying it as desired, and the fre- 
quent association of dominant lesions of the cord which cannot possibly 
be remedied. The condition of the cord, as indicated by the symp- 
toms, should usually determine the measure of benefit to be expected 
from treatment, but unfortunately we cannot distinguish with certainty 
between a complete division or crush of the cord which cannot be 
repaired and compression by bone or extravasated blood which will be 
recovered from if the pressure is relieved. We know that in the great 
majority of cases, a majority which is greater the higher the injury is 
situated in the vertebral column, the condition of the cord is hopeless 
or at the most can only be mitigated. 

In the first care of the patient — transport, undressing, examination 
— he must be handled with constant watchfulness to avoid producing 
or increasing displacement. Then, if the fracture is of a spinous pro- 
cess alone or of the column without recognizable displacement and 
without symptoms of injury of the cord, confinement to the bed, pref- 
erably aided by a plaster-of-Paris corset, is all that is required. 

If there is recognizable displacement — gibbosity of the spine — with- 
out cord symptoms immobilization in the plaster corset is indicated, 
with or without an attempt to correct the displacement. 

If symptoms of pressure on or injury of the cord coexist an attempt 
should be made to relieve the condition by correcting the displacement. 

The means of accomplishing this are traction upon the trunk to 
straighten it by elongation, direct pressure forward upon the project- 
ing angle, and open operation. 

When the injury is in the cervical or upper dorsal region traction 
can be made by turning the patient upon his side and pulling by the 
chin and occiput; and by gradually changing the direction of the 
traction by moving the head backward while pressure is made against 
the spine below the fracture the angular displacement can sometimes 
be completely corrected. But when the injury is at a lower point, and 
11 



162 



FRACTURES. 



especially if the patient is large and heavy, traction thus made is not 
sufficient even with the aid of anaesthesia ; and even pressure with the 
knee or hand against the angle (the patient being on his side) while 
the hips and shoulders are pressed backward may fail to make any 
change in the condition. 

Suspension by the apparatus used in disease of the spine has been 
employed by some with advantage, but I have not ventured to try it. 

Fig. 64. 




Fracture of spine. Correction of the displacement by suspension and plaster jacket. 



Instead, I have used a long plank, placing the patient upon it, secur- 
ing his shoulders to one end, and then gradually raising that end so 
that the lower limbs would make the desired traction by their weight. 
While the patient is thus supported pressure forward upon the angle 
can be made by a bandage or stick passed between it and the plank. 
If the materials for a plaster corset have been previously prepared, in 
the form of broad strips of muslin or canton-flannel soaked in plaster 
cream, and placed at the proper point upon the plank before the 
patient has been laid upon it, the dressing can be easily and rapidly 



FRACTURES OF THE VERTEBRA. 163 

completed while the patient remains suspended by bringing forward 
the ends of the strips around the body on each side. 

Dandridge recommends horizontal suspension on a narrow strip of 
stout muslin, like a hammock, which is then included in the plaster 
jacket. The method is praised by those who have employed it in 
Pott's disease of the spine. Or partial suspension can be made by a 
bandage resting against the angle of the gibbosity (Fig. 64). 

In a few cases an existing paraplegia has immediately disappeared 
during suspension, and although in others the symptoms have been 
temporarily aggravated I think we are justified in deeming the method 
safe and probably efficient to correct an angular displacement due to 
fracture or crushing of the body of a vertebra or of the pedicles or 
articular processes and also, though less certainly, a forward displace- 
ment of one segment. It cannot correct the much less common dis- 
placement forward into the canal of the posterior portion of the ver- 
tebral arch, the spinous process with one or both lamina?, or probably 
a fracture-dislocation in which one or both inferior articular processes 
of an upper vertebra have lodged in front of the corresponding supe- 
rior processes of the next lower one. 

In reduction by open operation a longitudinal incision is made along 
the median line with its centre at the apex of the angle of the frac- 
ture, and the soft parts separated on each side from the spinous process 
and laminae of the vertebra forming the upper part of the angle, cut- 
ting through both laminae, if unbroken, and removing them with the 
spinous process. If indicated the opening in the spinal canal is 
enlarged upward or downward by removal of the adjoining spinous 
process and laminae, and the displacement of the body of the vertebra 
is corrected by manipulation guided by the eye and perhaps aided by 
traction with a blunt hook passed into the spinal canal. Hemorrhage 
beneath the dura is relieved by evacuation through an incision. 

A large number of cases have been thus operated upon during the 
last few years, and apparently with marked benefit in some, but it is 
still too early to formulate a rule of practice. It is admitted by all 
that the operation can do good in only a small proportion of cases, 
and it is probable even that that proportion is less than is indicated by 
the statistics because it is not clear that the improvement which has 
sometimes followed was the result of the operation ; similar improve- 
ment has been noted in apparently identical cases not operated upon, 
some of them probably cases of haematomyelia. It must also be 
admitted, I think, that the operation is not likely to do harm and that 
occasionally it discloses an important condition which could not other- 
wise be recognized and corrected. My own inclination is strongly 
toward reliance upon traction and the plaster jacket, systematic use of 
which might show a gain as great as that which Bun-ell 1 found in the 
Boston City Hospital : 33 per cent, of recoveries as against 2'2 per 
cent, under expectant treatment. I believe, for reasons above given. 
that in the common form of injury with angular displacement — gib- 
bosity — reduction can almost always be accomplished as well in this 
way as by operation, and that the latter may find its special indica- 

1 Burrell : Annals of Surgery, February, 1895. 



164 FRACTURES. 

tions in eases of intraspinal hemorrhage and those rare ones in which 
the posterior portion of the arch is driven into the canal and presses 
upon the cord. Thorburn, 1 after a personal experience of seven cases 
of operation and study of about 200 published cases, says he has 
found no clear evidence of benefit from it. Nevertheless, he deems 
laminectomy justifiable " (1) in compound fracture ; (2) in injuries of 
the laminae and spinous processes with lesion of the cord when the 
crush is probably incomplete; (3) when the symptoms are mainly or 
entirely due to thecal or perithecal hemorrhage; (4) in pachymenin- 
gitis or peripachymeningitis, which may follow an injury after a very 
long period ; and (5) in cases of compression of the cauda equina." 

Of the great value of the plaster jacket, applied during suspension, 
in aiding consolidation of the fracture in cases in which the disability 
is due to the fracture rather than to injury of the cord, there can be no 
question. 2 

The general treatment, when paraplegia is present, is to place the 
patient upon a water-bed, carefully prevent irritation of the skin by 
moisture or creases in the sheets, and regularly empty the bladder and 
bowels. Later in the case electricity may render some service. 

1 Thorburn : Lancet, August 11, 1894. 

2 See Papail, De l'emloi du corset platre dans les lesions de la colonne vertebrale, 
Paris, 1887. 



CHAPTER XII. 

FRACTURES OF THE BONES OF THE FACE. 

1. Fractures of the Nose. 

Under this term we include not only the two nasal bones, but also 
those upon which they rest, the septum, the nasal process of the supe- 
rior maxillary, and the nasal spine of the frontal. The fracture may 
involve one or both nasal bones or adjoining processes ; it may be simple 
or compound, multiple or comminuted ; and it may be associated with 
other fractures of neighboring bones, the most important of which is 
fracture of the cribriform plate of the ethmoid. In the great majority 
of cases the fracture is a more or less comminuted one, occupying the 
lower half of the nasal bones, the main line of fracture running trans- 
versely or obliquely, and the fragments are displaced backward or back- 
ward and to one side, according to the direction of the force that has 
produced the injury. In rare cases the fracture involves only one 
nasal bone, or there may be dislocation of one or both bones. The 
cartilages which form the alse may be broken or torn from their attach- 
ments to the bone, and that which forms the septum is frequently 
broken in connection with fractures of the bones themselves, or sepa- 
rated from the vomer. 

The symptoms by which fracture may be recognized are deformity, 
mobility, and crepitus. If the nose is grasped by the thumb and finger 
lateral mobility with crepitus can usually be recognized, and displace- 
ments may at the same time be appreciated. The separation or fracture 
of the septum is recognized by exploration within the nostrils. The 
swelling of the soft parts, which appears promptly, will mask any but 
an extreme displacement. 

Other symptoms which may be present, but which are by no means 
pathognomonic, are free bleeding from the nose, and occasionally 
emphysema of the eyelids and face. Bleeding is often severe and 
sometimes recurrent and difficult to arrest, but rarely endangers life. 
Emphysema generally has its origin in an effort of the patient to blow 
his nose ; the air is forced into the subcutaneous cellular tissue through 
a rent in the mucous membrane and spreads promptly to the eyelids 
and sometimes over the rest of the face. 

An occasional symptom, when the fracture has extended into the 
adjoining portion of the superior maxillary bone, is obstruction to the 
flow through the lachrymal duct in consequence of its inclusion in the 
line of fracture. Another and more common one is the difficulty or 
impossibility of breathing through the nose, the result of inflammatory 
swelling of the mucous membrane; and, finally, in the comminuted 
fractures that are or have become compound, suppuration may be 

165 



166 FRACTURES. 

maintained for weeks or months until all the necrosed fragments have 
worked their way out or have been removed. It occasionally happens, 
too, that a tendency is manifested toward inflammatory complications 
in the neighborhood, abscesses form in and about the nose, portions of 
bone or cartilage become necrosed and are exfoliated, and a constant 
purulent discharge from the nostrils is maintained. 

It is so important that displacement should be corrected that an 
anaesthetic should be used if a thorough exploration cannot be made 
without its aid, and the surgeon should spare no pains to satisfy him- 
self as to the condition and position of the bones. The examination 
cannot prudently be long postponed, for the bones of the face unite 
promptly, and more than once it has been found impossible to correct 
a displacement after eight or ten days had elapsed ; firm union may be 
expected within a fortnight or three weeks. 

The prognosis as regards life is favorable, except in those cases in 
which the skul] is at the same time broken, and in those few others in 
which recurrent hemorrhages, of which no satisfactory explanation is 
given, show themselves. But as regards the avoidance of deformity 
the outlook is not so favorable, because it is not always easy to recog- 
nize or correct a displacement through the swollen tissues and the 
persistence of even a slight one is likely to be a noticeable blemish. 

The treatment consists mainly in the reduction of the displacement, 
for it is seldom possible to apply any apparatus or dressing that will 
prevent a recurrence of the displacement if there is any tendency 
toward it. The reduction when there is depression is accomplished by 
pressure made from within the nostril, upon the septum, if broken or 
displaced, as well as upon the bones, aided by manipulation or model- 
ling of the fragments on the outside. The interval between the septum 
and the side of the nose at the part of the nostril corresponding to 
the nasal bone is so small that a strong flat instrument, such as a perios- 
teum elevator, must be used, one that is small enough to work within 
the narrow space next the nasal bone, and strong enough to transmit 
considerable pressure. The fingers of the left hand placed upon the 
nose serve to guide the instrument and to recognize the degree of reduc- 
tion that has been obtained. Cocaine may be used to diminish the sen- 
sitiveness of the mucosa. Ordinarily there is but little tendency to 
recurrence of the displacement, except when the fracture is comminuted 
and the septum badly broken ; the only forces that tend to change the 
position of the fragments are the swelling of the external soft parts 
and the pressure of the air when the patient seeks to clear his nose by 
snuffing or blowing. 

The idea of supporting the fragments by pressure from within the 
nostrils suggests itself so readily that it is not surprising to find recorded 
many instances and several varieties in the methods of its use. The 
simplest one consists of packing the lower, and perhaps the middle, 
meatus on the side toward which the septum is displaced with strips of 
iodoform gauze for a few days, so as to hold the septum in place and 
thus support the nasal bones. This is the method which we have used 
for several years at the Hudson Street Hospital. The more elaborate 
ones are arrangements of rods supported by straps crossing the upper 



FRACTURES OF THE BONES OF THE FACE. 167 

lip, and capable of adjustment in length and direction within the nos- 
tril so as to hold the fragments in place ; they are said to have been 
efficient in some difficult cases. 

The use of plaster or gntta-percha splints moulded upon the outside 
seems to me to be entirely illusory ; if swelling takes place under them 
it will tend to reproduce the displacement by pressure, if it is present 
when the mould is applied its subsidence soon creates a gap between 
the splint and the skin. The best plan appears to be repetition of the 
reduction as often as the displacement recurs. Occasionally the bridge 
has been held up by transfixion with a pin which rests upon the solid 
bone on each side. Recurrence of a lateral displacement may be 
opposed by a pad of gauze secured against the side of the nose by a 
strip of adhesive plaster crossing both cheeks. 

Separation of the cartilaginous septum from the vomer can be treated 
with a pair of forceps, one branch of which is passed into each nostril, 
lapping and grasping the bone and cartilage so as to hold them in line. 
The depression of the bridge, the " saddle nose/' which so often is seen 
after this fracture, constitutes so marked a disfigurement that many 
attempts have been made to correct it. Operations upon the bone, 
designed to detach and raise the bridge, have, as a rule, failed so com- 
pletely that I . was led to try to meet the indication by introducing a 
suitably shaped foreign body between the skin and the bone. It proved 
entirely successful in restoring the profile, and the pieces of aluminum 
and gutta-percha have remained in place for several years without 
causing irritation. (Annals of Surgery, June, 1896.) Of late, sub- 
cutaneous injection of warm paraffin has proved very satisfactory. 

2. Fractures of the Malar Bone and Zygoma. 

Isolated fractures of this bone are rare, and, so far as can be inferred 
from the small number of cases in which a direct examination has been 
possible, single fractures are rarer than multiple ones, and the rarest is 
that which is almost a simple diastasis, a separation at the sutures with 
some splintering. Partial fractures involving the lower and outer por- 
tion of the bone or the margin of the orbit have been observed, and 
also single fractures of the frontal and zygomatic processes, extending 
possibly into the bones with which they articulate. In most cases there 
is depression of the entire bone with fracture of the malar process of 
the superior maxilla and crushing of the anterior wall of the antrum, 
the malar bone being displaced inward toward the antrum or sometimes 
backward into the zygomatic fossa. The force and direction of the 
violence may be such that adjoining portions of the cranium will be 
broken, with possible laceration of the brain. 

Fractures of the zygomatic arch alone have been caused by external 
violence acting from without inward, and in two cases from within 
outward, the patient having fallen forward upon a stick held in the 
mouth. In some of those I have seen a portion of the arch has been 
separated by two lines of fracture and depressed ; in one of them one 
of the lines of fracture extended into the temporo-maxillary joint. 
The displacement follows the direction of the fracturing force. 



168 FRACTURES. 

The symptoms upon which the diagnosis must be made are deformity, 
mobility, and crepitus. Unless there is much inflammatory swelling 
the deformity, which consists usually in a depression or flattening of the 
cheek just below the outer half of the eye, can be recognized by sight 
and touch, and the irregularity of the line of fracture can be readily 
felt on the margin of the orbit, or, if it extends to the malar process 
of the superior maxillary bone, on the under and anterior surface of 
this process by the finger within the mouth. Mobility and crepitus 
are perceived more rarely ; the latter can be sometimes produced by the 
movement of the jaw. 

Anaesthesia or a sense of formication in the cheek, nose, upper lip, 
and gum of the corresponding side is sometimes observed, and is due 
to an extension of the fracture to the infra-orbital canal and tearing or 
bruising of the superior maxillary nerve. This symptom may be asso- 
ciated with the extravasation of blood in the posterior part of the orbit 
sufficient to force the eye forward and showing itself also under the 
conjunctiva and in the eyelids. Bleeding from the mouth or nose is 
occasionally seen as the result of the extension of the fracture through 
the mucous membrane of the mouth or antrum. 

When the fracture involves the zygomatic arch, and the fragments, 
as is usually the case, are driven inward, movement of the jaw may be 
difficult or impossible, either because the masseter has been injured, or 
because the depressed fragments of the arch are forced against the 
coronoid process of the inferior maxilla, or into the tendon of the tem- 
poral muscle. In one case the tip of the coronoid process was broken 
off by the same blow that fractured the arch. The same interference 
can be produced by the displacement backward of the main portion of 
the bone. Swelling, discoloration, and pain are the natural and con- 
stant results of the fracture and the bruising of the soft parts. 

The natural course of these fractures is toward rapid repair without 
excessive callus, and with gradual disappearance of any difficulty that 
may exist at first in the movement of the jaws. It is seldom possible 
to reduce the displacement completely, because, as has been said, it is 
generally inward, and there is no way of acting very efficiently upon 
the bone, except through a wound of the skin. The attempt must be 
made to move the bone in the desired direction by engaging the end 
of the thumb or finger under it in the zygomatic fossa, introducing it 
through the mouth if the cheek is swollen. It has been proposed, and 
occasionally practised, to cut down upon the bone opposite the zygo- 
matic process, divide the fascia overlying the masseter muscle, pass a 
stout hook under the process, and raise the bone by drawing upon it, 
or to make a smaller incision over the body of the bone and screw an 
elevator into it, by which it could then be raised. 

Inward displacement of the zygomatic arch cannot be directly acted 
upon except by a hook introduced through the skin or an incision. In 
only one of the recorded cases has the displacement interfered seriously 
and for any length of time with the movement of the jaws ; in this 
one the difficulty increased steadily for some time until the patient 
could barely separate the teeth, and then one morning while yawning 
he felt something snap, and the motion of the jaw at once became and 
remained free. 



FRACTURES OF THE BONES OF THE FACE. 169 

3. Fractures of the Superior Maxilla. 

While the body of this hone, protected as it is by outlying processes 
and other bones, is rarely fractured, its own processes are not infre- 
quently broken or involved in the fractures of those bones with which 
they are continuous. Thus, a blow upon the nose breaks not only the 
nasal bones but also the nasal process of the superior maxilla, and a 
blow upon the malar bone may force in the anterior wall of the antrum 
on which it rests. The fractures are always produced by direct vio- 
lence, and present, consequently, considerable variety in their extent 
and the parts involved, but a fissure may extend to this bone from a 
fracture of the cranium. The alveolar process may be broken off in 
part or entirely by a blow received on it or on the teeth. A blow 
received in front, at or below the level of the nostrils, may produce a 
horizontal line of fracture separating the alveolar and palatal processes 
from the body of the bone, and including also the pterygoid plates. 
Falls from a height have caused a vertical line of fracture or diastasis 
between the two bones along the median line of the mouth, extending 
even through the soft palate, and associated with fracture of the malar 
or nasal bones. In a very few cases a line of fracture on each side at the 
canine tooth has separated the intermediate portion, Avith marked dis- 
placement and mobility. Fractures of the alveolar process, even with 
much displacement and mobility, present but little gravity, for they 
heal rapidly and without necrosis except of small pieces of the sockets 
of teeth displaced at the same time. 

It occasionally happens that one or both bones are driven in with 
multiple and comminuted fracturing of them and of the adjoining 
ones. The earliest known case of the kind was reported by Wiseman, 
and has been extensively quoted. The upper jaw was driven in so 
far that the finger could not be introduced between the palate and the 
posterior wall of the pharynx. Wiseman inserted a blunt hook through 
the mouth and easily drew the bone forward into place; as, however, 
the displacement recurred very easily, he left the hook behind the 
palate and had it drawn upon constantly by the patient or his friends 
until consolidation had taken place. Quite a number of similar cases 
(Gurlt collected upward of twenty) have been reported, all the 
result of great violence, either by falls from a height or the passage 
across the face of a heavy wagon, or a violent blow. In one of my own, 
a blow by a descending elevator upon an upturned face, the nasal bones 
were separated from the frontal along the suture line, the right malar 
and zygoma broken, and both superior maxilke displaced downward and 
backward and separated from each other along the median line of the 
hard palate. In one case the bones of the face were so movable that 
they moved up and down when the patient swallowed, as if they were 
restrained only by the skin. In most of them the patients recovered, 
and it is worthy of remark that, notwithstanding the degree of the vio- 
lence and the extent of the injury, it seldom happens that the fracture 
involves the cranium. The reason lies apparently in the direction in 
which the fracturing force is applied, a direction outside of and more 
or less parallel to the surface of the cranium and not in the line of one 



170 FRACTURES. 

of its diameters. The bones of the face are, as it were, torn off the 
cranium rather than driven back upon it. 

Very extensive mutilation of the face has been caused by gunshot 
wounds, especially in attempts at suicide when the muzzle of the gun 
has been placed within the mouth, but it is rare for ordinary violence 
to lead to much loss of tissue. Malgaigne speaks of the following case 
as unique in this respect in his experience : A boy was kicked in the 
face by a horse ; the superior maxillary, nasal, and palatal bones were 
extensively comminuted, and the skin torn and bruised. Recovery 
took place, but with much deformity. The nasal bones, the anterior 
portion of the alveolar arch, and the greater part, if not all, of the 
hard palate had disappeared. There was no longer either nose or 
mouth ; the lips were united by a firm cicatrix, and the mouth and 
nostrils were represented by an oval opening between the nasal pro- 
cesses of the superior maxilla?. Through this opening the patient 
breathed, spoke, drank, and ate. 

The diagnosis of fracture is ordinarily made without any difficulty, 
since large portions of the bone are open to direct examination with 
the finger through the mouth and on the cheek. Irregularity of out- 
line, mobility, displacements, and crepitus can be readily recognized. 
In some few cases where there was no displacement the diagnosis has 
been in doubt, and Guerin 1 has pointed out a symptom which might 
be useful under such circumstances. It has been said that the ptery- 
goid apophysis is always broken when the line of fracture crosses the 
jaw horizontally between the alveolar process and the malar bone, and 
Guerin found that pressure with the finger upon the inner plate of this 
process caused pain and sometimes showed mobility when there was no 
other sign of fracture. Ecchymosis of the hard or soft palate indicates 
fracture. 

Repair in cases of average severity takes place in from thirty to 
forty days with a scanty formation of callus, and not infrequently in 
less time. The vitality of the bone is exceptionally great, hence the 
rule laid down by Malgaigne and some of his predecessors, and 
repeated by all subsequent writers, to leave every fragment that is not 
absolutely and entirely detached. Although the rule is a sound one, 
it occasionally happens that fragments become necrosed and have to be 
removed. This is thought to happen more frequently with fragments 
of the alveolar border than with any others. 

Displacement is seldom noticeable after repair is completed, except 
in the nose, but it usually exists to a greater or less degree, and the 
ingenuity and the patience of the surgeon are often severely taxed to 
overcome the constant tendency to the recurrence of the displacement. 
Salivation is often profuse, and the discharge offensive. Division of the 
lachrymal canal by the fracture may lead to its obliteration. 

Displacement of the entire bone may be treated as in Wiseman's 
case, or the retention may be aided by securing the lower jaw against 
the upper one, with or without the intervention of interdental splints 
or moulds of gutta-percha or metal shaped to fit the teeth and alveolar 
arch. Lateral pressure cannot well be made upon the cheeks to over- 

1 Guerin : Archives Generates de Medecine, July, 1866, vol. ii. p. 5. 



FRACTURES OF THE BONES OF THE FACE. 



171 




come separation along the median line of the palate, but fortunately it 

is not always necessary. In Simonin's case, quoted by Maigaigne, the 

gap began to contract spontaneously by the tenth 

day, and was completely closed by the thirty-third, 

with no other displacement than a slight difference 

in level between the two halves. In another case, 

quoted by Hamilton, the gap was large enough to 

admit the little finger, and was still open six weeks 

after the receipt of the injury. 

After fracture of the alveolar process the frag- 
ment should be carefully readjusted and fixed by 
wiring the teeth to the adjoining ones, or by a splint 
of gutta-percha or metal. Agnew says he has used 
for this purpose with great advantage a piece of 
cork with grooves cut in its upper and lower sur- 
faces to receive the teeth of both jaws. The reduc- 
tion is made, the cork inserted, and the jaws firmly bound together. 
No attempt should be made to remove the corresponding teeth, for not 
only are the chances in favor of their becoming firm again in their 
sockets, but the attempt to draw them, even if they are loose, may 
bring away an important piece of the bone. 

The gutta-percha or metal mould may be held in place by binding 
the lower jaw against it after it has been fitted to the upper one, or by 
an apparatus similar to one devised by Graefe for the purpose, and 
shown in Fig. 65. If the splint is to be supported by the lower jaw 
it should be so constructed that an interval will be left, through winch 
food can be given and the mouth cleansed. The cavity of the mouth 
should be repeatedly cleansed. 



Intrabuccal splint for frac- 
ture of the upper jaw. 



4. Fractures of the Inferior Maxilla. 

Fracture of the inferior maxilla occurs more frequently than that of 
any other of the bones of the face. It is rare in childhood and old 
age, most frequent between the ages of twenty and thirty, and is appar- 
ently more than ten times as common in males as in females. 

Gurlt collected 143 published cases in which the character and posi- 
tion of the fracture were described with sufficient accuracy to allow of 
their use as statistics: of these 80 were single, 49 double, and in 14 
there were three or more lines of fracture. Of 75 single ones (exclud- 
ing 5 in which the fracture was limited to the alveolar process) the 
fracture occupied the median line in 25, the region of the incisor teeth 
in 22, that of the back teeth in 15, behind the teeth in 8. and the con- 
dyloid process in 5. In 85 double fractures both halves of the bone 
were broken 20 times, and at points on the two halves corresponding 
closely with each other ; one side alone 8 times, and the median line 
by one of the fractures 7 times. One or both of the condyloid pro- 
cesses were broken in several of the multiple fractures. These figures 
show that, exclusive of partial fractures of the alveolar border, which 
are very common, and often caused by the drawing of a tooth, the most 
frequent seat of fracture is at or near the median line, and that single 
fracture of the ramus, or of the alveolar or condyloid process is com- 



172 FRACTURES. 

paratively rare. They differ materially from the estimates made by 
various writers, but as the latter differ quite as much among them- 
selves, and appear to have spoken in most cases from general impres- 
sions rather than from figures, the preference should be given, I think, 
to Gurlt. 

Double fractures of the lower jaw are relatively more common than 
those of other bones, while comminuted ones are rare. Compound 
fractures are common, both because the gum overlying the fracture is 
frequently torn and because the lip and skin are often involved in the 
direct injury that has caused the fracture. The fracture is complete or 
incomplete, the latter rarely except when the alveolar border alone is 
involved. A portion of the lower border of the bone may be broken 
off by a blow. 

The line of fracture in the body of the bone is usually vertical or 
nearly vertical ; at the angle or in the ramus it is oblique or rarely 
transverse. At the median line there is but little displacement, if 
any ; but, when present, it may be in either of three directions : a 
difference in the horizontal level of the edge of the teeth, a displace- 
ment forward and backward of the fragments upon each other, or a 
lateral separation of the two. In the fractures between the median 
line and the canine tooth the line is still much more frequently vertical 
than oblique ; but displacement is the rule, although no one form of it 
seems to be more common than the others. Between the canine tooth 
and the angle of the jaw it is either vertical or inclined backward and 
doAvnward, and usually, instead of crossing the bone from without 
inward at a right angle to the surface, it is inclined backward and 
inward, so that the anterior fragment is lengthened on the inner side 
and the posterior fragment on the outer side. The inferior dental 
nerve is crossed by this fracture, and is sometimes torn or bruised. 

Fracture behind the teeth is comparatively rare, only eighteen cases 
being contained in Gurlt's statistics, and it is frequently double or 
multiple or associated with other fractures. 
Fig. 66. When the fracture lies at the junction of the 

body of the jaw and the ascending ramus, it 
is usually oblique, running from behind the 
last tooth backward and downward toward the 
angle of the jaw ; but it may be vertical. 
Displacement is usually slight or lacking, the 
parts being kept well together by the masseter 
and internal pterygoid muscles (Fig. 66). 

Fracture of the condyloid process is usually 
accompanied by other fractures of the same 
or other bones of the face, and may be pro- 
Fracture of lower jaw behind duCe< ? h Y a bloW either U P 0n the chin 0r ll P 011 
the teeth. the side of the jaw near the joint. The line 

of fracture passes through the neck, and the 
few specimens furnished by autopsies and museums do not show a 
greater frequency at any point or in any direction than at any other. 

Fracture of the coronoid process is exceedingly rare and has been seen 
only in association with other fractures of the same or adjoining bones. 

A portion of the alveolar process with the teeth in place is some- 




FRACTURES OF THE BONES OF THE FACE. li?j 

times broken off. The size of the piece varies within wide limits, and 
the displacement is habitually inward. In one or two entirely excep- 
tional cases a similar piece, including a portion of the body of the 
bone, has been broken off. 

Comminuted fractures, except as the result of gunshot wounds, are 
comparatively rare ; double and treble fractures are less so ; and one 
case is on record in which there were five distinct and separate lines of 
fracture. 

The most frequent cause of fracture, exclusive of partial fractures 
produced by attempts to draw a tooth, is violence received upon the 
chin ; fracture by pressure upon the sides is much less common, the 
other occurring thrice as frequently. Fracture of the condyloid pro- 
cess may be produced in either of the same two ways — a blow upon 
the chin or upon the cheek. 

The objective symptoms of fracture of the lower jaw are the same 
as those of other fractures : abnormal mobility, crepitus, displace- 
ment, pain. The bone is so accessible to the touch both within and 
without the mouth that irregularities in the outline of its body can be 
easily recognized by the fingers and sometimes by sight. The teeth 
show differences in level, vertically or antero-posteriorly j those which 
adjoin the fracture are usually loosened and may be entirely dis- 
lodged. Mobility and crepitus are detected by manipulation. When 
the fracture is situated at or above the angle of the jaw its recognition 
is by no means so easy ; by passing the finger within the mouth along 
the inner and outer surfaces of the ramus irregularities of outline and 
localized points of pain may be recognized, and pain at a fixed point 
is caused by biting. 

The degree and direction of the displacement vary much. As a 
rule, when the fracture is single and lateral, the anterior fragment 
tends toward the inside of the mouth. In double fractures, the inter- 
mediate piece is almost invariably drawn downward and backward by the 
unopposed action of the muscles of the neck which are attached to it. 

Fracture of the condyloid process was first studied by Desault and 
Bichat, and but little if anything has been added to our knowledge of 
the subject since their time. The symptoms are pain, increased by 
motion, diminished mobility of the jaw, often crepitus on manipulation, 
irregularities in the region of the condyle, the ease with which the con- 
dyle can be pushed forward into the zygomatic fossa, its failure to share 
in the movements of the jaw, and its almost constant displacement 
forward by the contraction of the external pterygoid. Ribes pointed 
out an additional symptom which is sometimes present, deviation of the 
chin toward the affected side. This is effected by the displacement of 
the ramus upward and backward on the outer side of the condyle and 
neck, and the more easily if the fracture is a double or multiple one. 
Gurlt quotes the description of a specimen of this kind from a work by 
Bonn, published in 1785. The condyle was united by a bony callus to 
the ramus just above the orifice of the dental canal. 

Swelling of the gums, face, and glands follows promptly upon the 
injury, and is often increased by the direct bruising of the soft parts 
themselves; the secretions of the mouth, increased in quantity by the 
irritation, mingle with the pus that comes from the fracture it' com- 



174 FRACTURES. 

pound or from the ulcers produced by the stomatitis, decompose, aud 
cause an offensive odor that can scarcely be kept under control even by 
the most careful attention. Abscesses may form and open within the 
mouth or upon the sides of the jaw or the neck below it ; they are 
almost invariably associated with the presence of detached splinters or 
the exfoliation of portions of the jaw, which require, of course, to be 
removed before a permanent cure can be obtained. Small fragments 
may long escape recognition, and the only indication of their presence 
may be a sinus; larger fragments force themselves promptly upon the 
surgeon's attention by the profuseness of the discharge and the amount 
of local reaction. A few cases of extensive necrosis have been reported. 

Simple fractures unite in from thirty to forty days, and, even when 
there has been a considerable loss of bone by splintering or necrosis, 
the final result may be a very good one, in this sense, that the jaw is 
strong enough to support artificial teeth in the place of those that 
have been lost by the accident, is sufficiently regular in form to avoid 
deformity, and is free in its movements. 

Failure of union, pseudarthrosis, is rare. Gurlt's statistics contain only 
two cases which can be properly considered as such, and they were both 
cured by operation. It is more common after fracture with much loss of 
substance by elimination of splinters, and may interfere with mastication. 

The prognosis is a relatively favorable one ; the probabilities are that 
union will take place promptly, that no serious complications will arise, 
and that no important deformity or disability will remain. Danger to 
life may come from two quarters : the proximity of the bone to the 
cranium carries with it the possibility of associated injury to the brain 
or to its case ; retention of pus in a compound fracture in communica- 
tion with the cavity of the mouth exposes to the grave danger of absorp- 
tion of the decomposed secretions and, though rarely, to the burrowing 
of the decomposed pus along the deeper planes of the neck into the 
anterior mediastinum. 

Treatment. Displacement following fracture of the body of the jaw 
can usually be readily overcome by the pressure of the thumb and 
fingers upon the teeth and the lower border of the bone ; in some 
cases the interlocking or wedging of the smaller pieces or of displaced 
teeth may render the reduction impossible until after they shall have 
been removed. 

In simple cases where the tendency to displacement is slight it is 
sufficient to immobilize the lower jaw by binding it against the upper 
one with a four-tailed bandage, the centre of which is at the chin, as 
shown in Fig. 67. 

Splints are applied either to the front and under surface of the jaw 
outside the mouth, or to the teeth, or the inner surface of the jaw, and 
two kinds are sometimes used in combination. Outside splints are 
available only in cases in which there is not much tendency to displace- 
ment and in which the lateral pressure of a simple bandage would 
cause the fragments to override in one direction or another. They 
may be made of leather, pasteboard, gutta-percha, or plaster of Paris, 
and consist essentially of a cup-shaped piece embracing the chin and 
extending nearly to the angle of the jaw on each side, and to the fold 
of the neck below. 



FRACTURES OF THE BONES OF THE FACE. 



17 5 



Interdental splints are made of metal, gutta-percha, or vulcanized 
rubber ; they are fitted to the crowns of the teeth of both fragments 
after reduction of the displacement, and are held in place either by 
binding the jaws together with an outside bandage, or by braces con- 
necting the splint with a pad under the jaw, or by a special arrange- 
ment of lateral braces as in Kingsley's apparatus (Fig. 68), or by 
fastening them to the teeth with wires. Some are fitted only to the 
broken jaw and are intended only to immobilize the fragments on each 
other ; others are fitted to both jaws and enable the upper one to be 
used as a splint for the lower. Ackland l describes one capable of ready 
adjustment to almost any fracture of the body : a metal gutter partly 
filled with softened gutta-percha, pressed down upon the teeth, and 
secured to a plate beneath the chin by two adjustable clamps. 



Fig. 67. 



Fig. 68. 




Four-tailed bandage for fracture of the 
lower jaw. 



Kingsley's splint applied. 



In one difficult case I used a carpenter's small wooden vise, one end 
of which lay on the edge of the teeth, the other under the chin ; after 
a few day's use the displacement ceased to recur. 

Gutta-percha splints may be made either of thin strips or of thick 
lumps or wedges. The former have a length of three or four inches, 
and a breadth sufficient to overlap the crowns of the teeth from gum to 
gum ; they are softened by immersion in hot water, moulded to the teeth, 
cooled as rapidly as possible, taken off, and trimmed suitably. Then 
the splint is reapplied and the jaws bound together. If the tendency 
to displacement is slight the bandage may be loosened during the day 
to allow the introduction of liquid food, or a wedge may be kept 
between the jaws so as to create an interval to be used for this purpose. 
or advantage may be taken of the absence of teeth, especially from the 
upper jaw. In a ease quoted by Gurltr 2 two fragments oi^ the alveolar 

1 Ackland: British Medical Journal, April 1. 1893, 

2 Gurlt: Loc. cit., vol. ii. p. ;>5K>. 



176 



FRACTURES. 



border carrying eight teeth were secured by a splint of sheet lead 
moulded to the teeth and fastened down by silver wire, the ends of 
which were brought out under the chin by means of a needle and tied 
over a roll of plaster. The wire caused no irritation and was left in 
place forty-seven days. 

Gutta-percha wedges were introduced by Dr. Hamilton -to meet a 
double indication, that of fixing the fragments securely and of allow- 
ing the easy introduction of food. Two pieces of gutta-percha of suit- 
able size are softened and formed into wedges and introduced between 
the jaws, the edge of the wedge directed backward. The jaws are 
closed upon them, the fragments pressed up until the line of the teeth 
is straight, and the wedges moulded to the sides of the teeth above and 
below. As soon as the gutta-percha has hardened it is removed, trimmed 
suitably, and reapplied, and the jaws are bound together with a bandage. 



Fig 




Kingsley's interdental splint. 

Vulcanized rubber is a valuable substitute for gutta-percha in some 
difficult cases, but its employment requires special skill and experience 
which are found usually only among the dentists. Casts of one or both 
jaws are first taken in wax ; from these plaster models are made, and 
upon these latter the splint. Figs. 68 and 69 show the splint as made 
by Dr. Kingsley, of New York, with attached bars by which the splint 
and jaw can be bound firmly together, the bandage passing from one 
bar to the other underneath the chin. 







Fig. 70. 










,a 


fft 


jr' 


if 


jf~ 




/-■' i 


* '■■''. * ' 


m 


1/ J 


P 


* , 


V 



Matas's splint. 



The Matas * splint (Figs.' 70, 71, 72) is said to be easily adaptable to 
individual cases of fracture of the body of the jaw, and consequently 

1 Matas : Annals of Surgery, January, 1905. p. 1. 



FRACTURES OF THE JAW. 
Fig. 71. 



177 




Matas's splint for fracture of lower jaw, 



Fig. 72. 




12 



Matas's splint. 



178 



FRACTURES. 



Fig. 73. 




Hammond's wire splint for fracture of 
the jaw. 



of value in hospital service. It consists of a gutter of soft block tin 
roughly shaped to the line of the teeth and attached by hinged rods to 
a cup-shaped chin-plate of aluminum, as shown in the figures. The gutter 
is notched on each side so that it may be more easily fitted, and it should 
be partly filled with dental wax so as to fit snugly about the teeth. 

Another method, which dates back 
to Hippocrates, is to fasten together 
the teeth on opposite sides of the frac- 
ture by thread. In some cases I have 
found this to answer perfectly, in 
most to fail entirely. The ligature 
should be attached to the second or 
third tooth from the fracture on 
each side, and should be drawn very 
tight. 

A wire loop exactly moulded to the 
sides of the teeth and secured to them 
at several points by encircling loops 
(Fig. 73) has been found efficient; 
also Angle's 1 "anchor splint," in which 
the wire is attached to the teeth by 
metal collars cemented on. In a few 
cases it has been found effectual to bind the jaws together by ligatures 
applied to opposing teeth. 

Direct suture of the fragments by stout wire passed through holes 
drilled well below the alveolar border is said by Konig to be the 
method which he has employed exclusively for several years. Others 
have passed the suture through holes drilled in the lower border of the 
bone through an incision beneath the chin. 

Repair takes place so rapidly that, except in compound fracture with 
much suppuration, there is rarely any tendency to displacement after 
the tenth day, and, therefore, the discomforts incidental to the contin- 
uous closure of the jaws do not need to be borne for any great length 
of time. If the importance of the case warrants it, if the displacement 
can be prevented only by keeping the jaws constantly in contact with 
each other, the patient can be fed through a tube passed behind the last 
molar tooth, or through the nose, or by the rectum. 

Cleansing and disinfecting washes containing chlorate of potash, 
borax, or alum will be found to add much to the comfort of the patient 
whenever they can be used. 

In two fractures of the lower part of the ramus Knapp 2 obtained 
good results by pressing the anterior fragment forward and upward by 
means of a strap of adhesive plaster crossing beneath the jaw and at- 
tached above to the end of a long piece of tin projecting in front of the 
forehead and shaped to the top and back of the head and made fast 
thereto by a plaster-of-Paris bandage. 



1 Angle : Medical Record, August, 1890. 

2 Knapp : Medical News, February, 27, 1904, 



FRACTURES OF THE JAW. 179 

After fracture of the neck of the condyle the tendency is to the dis- 
placement of the condyle forward by the traction of the external ptery- 
goid muscle, and as the fragment is too small to be acted upon directly 
by any dressing this tendency, if manifested, cannot well be overcome. 
The treatment, therefore, is to reduce the displacement if it exists, and 
then to immobilize the jaw after having pressed it upward to inter- 
lock the fragments. Ribes reduced the displacement by passing his 
forefinger into the mouth and along the inner side of the ascending 
ramus until be reached the condyle and was able to press it back into 
place. Fountain obtained a good result by drawing the jaw well for- 
ward and wiring the teeth together, so as to maintain the position. 

Fracture of the coronoid process is not open to any treatment except 
immobilization. 

Fractures of the alveolar border are best treated, like fractures of 
the body, by immobilization after careful reduction of the displace- 
ment, and it is advisable not to make haste to remove loose or semi- 
detached teeth. They may become firmly adherent again, or, if this 
should fail, they may be removed subsequently without having caused 
any serious trouble or delay. 

Delayed union and pseudarthrosis are to be treated by the removal 
of the cause, if any definite local one exist, or by operative interference, 
freshening of the surfaces of fracture, and wiring of the fragments. 

When a gap has been created by loss of bone, every effort should be 
made to keep the fragments in proper position, for it will usually be 
maintained spontaneously after the lapse of two or three weeks. 



CHAPTEE XIII. 

FRACTURES OF THE HYOID BONE. 

This comparatively rare lesion has received the attention of writers 
only within the present century. Malgaigne collected 8 cases, Hamil- 
ton added 2, and Gibb 3; in 1864 Gurlt collected 27 cases, 21 being 
of the bone alone, while in 6 there was associated fracture of the thy- 
roid or cricoid cartilage or of the trachea. I have seen 3 of the 
greater cornu and 2 others were received at the Hudson Street Hospital 
in 1902 and 1903, which I did not see. In 3 of Malgaigne's cases and 
in 5 additional of Gurlt's the fracture was caused by hanging, judicial 
or suicidal, one of the latter surviving ; in 6 of these one of the greater 
cornua was broken, in the remaining 2 the body. In the other cases 
of the li*t the cause was violent grasping of the neck, or a blow, or fall, 
and in 2 cases apparently muscular action, general muscular contrac- 
tion during a fall. Valsalva reports a case of " dislocation of one of 
the greater horns from the body," caused by the eifort to swallow a 
large piece of food. 

In the great majority of the cases the fracture was of one of the 
greater cornua, and usually at or near its junction with the body. In 
only three cases was the body of the bone broken, and in none the 
lesser horn. 

Symptoms. The symptoms of fracture of one of the larger cornua, 
without accompanying injury to the larynx or trachea, are, according 
to the records, quite well defined and characteristic : sharp pain at the 
seat of fracture increased by pressure, speaking, or swallowing ; swell- 
ing in the same region appearing soon after the accident and due in 
part to extra vasated blood ; recognizable displacement or mobility of 
the fragment ; crepitus ; and sometimes free bleeding into the mouth, 
the result of perforation of the mucous membrane of the pharynx by 
the bone. Exploration of the pharynx will enable the surgeon to 
recognize displacement of the horn inward and perforation of the 
mucous membrane if they exist. The patient is seldom able to move 
the tongue freely or without pain, and in some cases attempts to 
depress it or put it out have caused paroxysms of suffocation. In all 
the cases it has been difficult to swallow, even a drop of water some- 
times causing the patient to cough and choke, and in many of them it 
was necessary to give food through an oesophageal tube, in one case 
for twenty days. In my own cases there was localized pain on press- 
ure, and the mobility of the cornu could be recognized by grasping the 
bone with the thumb and finger on either side of the neck. The sub- 
jective symptoms Avere not urgent except when fracture of the larynx 
was associated ; one such died by suffocation while tracheotomy was 
being done. 

In the single case in which a fracture of the body of the hyoid bone 

180 



PLATE V 




Fracture of the Hyoid Bone. 



FRACTURES OF THE HYOID BONE. 



181 



Fig. 74. 



was observed during life the symptoms were severe paroxysms of 
coughing, dyspnoea, lividity of the face, and abundant bloody sputa, 
and were relieved by the reduction of the displacement. 

The local and general reaction after the injury has been quite 
marked and although the bone appears to have united promptly con- 
valescence has been delayed by the persistence of the dysphagia and 
of the change in the voice. In two cases an abscess formed at^the seat 
of fracture, and three months afterward the necrosed posterior frag- 
ment was cast out. In an unreported case of which I have heard a 
sluggish abscess without necrosis formed, and the diagnosis was made 
when the pus was evacuated. 

The possibility of repair by a bony callus is shown by three speci- 
mens : one, taken from the body of an adult man without a history 
and presented to the London Patho- 
logical Society by Gibb, showing a 
fracture of the right greater horn which 
had united with overriding to the ex- 
tent of one-quarter of an inch, and dis- 
placement inward ; another (Fig. 74) 
in the pathological collection of the 
college at Brunswick, showing "a frac- 
ture of the right greater horn united 
with some shortening and displacement 
downward ; the third, 1 found in the 
dissecting-room, a fracture at the junc- 
tion of the left cornu and body, united 
with angular displacement. 

Prognosis. The prognosis, so far as 
life is endangered by the injury to the 
bone, is favorable, but the associated 
have often been such as to cause death, 
ries fracture of the larynx is prominent. 

Treatment. The treatment requires the reduction of displacement, 
if possible ; and this might be facilitated by the introduction of the 
finger into the pharynx. It is unlikely that a bandage would be of 
any service in opposing a tendency to the recurrence of displacement. 
Immobilization of the head and neck by a stiff collar has been sug- 
gested. 

The dysphagia may render nourishment through an oesophageal tube 
necessary, and associated injury of the larynx may require tracheotomy. 

1 Scriber : Medical Age, Detroit, January, 1892. 




United fracture of the hyoid boae. 

(GURLT.) 

njuries in the recorded cases 
Among these associated inju- 



CHAPTEE XIV 



FRACTUKES OF THE CARTILAGES OF THE LARYNX AND 

TRACHEA. 

This injury, although actually rare, is more frequent and much more 
dangerous than fracture of the hyoid bone and has received more atten- 
tion from writers. Gurlt's collection published in 1864 contained 47 
cases, Dr. Hunt l collected and analyzed 27 cases but did not give the 
details, andHenoque 2 collected 52 cases, to which Mr. Durham 3 added 
10, making 62 in all, or including 4 of Gurlt's in which the trachea 
alone was injured, QQ. Piatt 4 reports one terminating fatally by 
broncho-pneumonia in three days, and Stephens 5 one combined with 
fracture of the hyoid, followed by death in a few minutes. 

The following table shows the relative frequency with which the 
different parts are affected : 



Cartilage broken. 


Cases. 


Deaths. 


Recoveries 


Thyroid alone 


24 


18 


6 


Cricoid alone . . ." 


11 


11 




Thyroid and hyoid bone • 


5 


3 


2 


" " cricoid 


9 


9 




" " " and hyoid bone 


2 


2 




" " " " trachea 


2 


2 




Cricoid and trachea 


2 


2 




" " " and hyoid bone 


1 


1 




"Larynx" 


7 


3 


4 


Trachea alone 


. 4 


3 


1 



67 



54 



13 



The causes are blows, falls, hanging, and the grasp of the hand in 
a fight, or in an attempt to strangle. The injury is seen more fre- 
quently in males than in females, and in middle life than at any other 
period, but youth and old age are not exempt. The mechanism of the 
fracture of the thyroid or cricoid is usually either lateral compression on 
both sides or pressure backward against the vertebral column ; the first 
causes commonly longitudinal fracture of the thyroid cartilage near its 
middle, together with flattening or depression of its sides, and either a 
double lateral fracture of the cricoid cartilage or a single fracture in the 
anterior median line ; the second causes irregular and multiple lines of 
fracture. The mucous membrane of the larynx is frequently torn, and 
extravasations of blood take place under the skin and mucous mem- 
brane or among the muscles. 

1 Hunt : American Journal of the Medical Sciences, April, 1866, p. 378. 

2 Henoque : Gazette Hebdomadaire, Sept. 26 and Oct. 2, 1868. 

3 Holmes's System of Surgery, American edition, vol. i. p. 697. 
* Piatt : Med. Chronicle, Dec, 1899. 

5 Stephens : Guy's Hospital Reports, vol. liv., 1900. 

182 



FRACTURES OF CARTILAGES OF LARYNX AND TRACHEA. 183 

Symptoms. — The symptoms of fracture of the larynx are frothy 
bloody expectoration with convulsive coughing and usually much 
dyspnoea and its attendant symptoms. The voice is affected or lost, 
and swallowing often difficult and painful, although not so much so as 
after fracture of the hyoid bone ; and in all severe cases, when there 
is laceration of the mucous membrane, emphysema appears promptly 
and spreads steadily over the neck, face, trunk, the extremities, and 
mediastinum, being sometimes more marked in the intermuscular than 
in the subcutaneous connective tissue and sometimes causing pneumo- 
thorax without wound of the lung. 

The additional objective symptoms are deformity of the region and 
abnormal mobility of parts of the larynx upon each other, but both 
these signs may be unrecognizable on account of the swelling. I have 
seen one case in which the only symptom was the mobility with crep- 
itus of a small fragment at the upper posterior angle of the larynx ; 
there was also slight hoarseness. 

In some cases there have been no marked symptoms beyond a change 
in the voice, although the character of the injury was made clear by 
careful examination, and the difference seems to be due to the absence 
in these cases of any obstruction or narrowing of the air-passages by 
displacement or swelling. 

The course in the severe cases is toward prompt death by suffocation, 
either by gradual increase of the dyspnoea or by the sudden intercur- 
rence of oedema of the glottis. Occasionally the dyspnoea does not 
make its appearance until some days after the injury. In the mild 
cases the symptoms gradually subside, and recovery follows. 

It seems probable that repair is by a bony, or at least by a calcified, 
callus. 

Treatment. The treatment in the milder cases consists of local anti- 
phlogistics and quiet ; in the severer ones, of tracheotomy whenever 
the dyspnoea is great or increasing. It is not safe to wait until it has 
become extreme, for its increase at the last is often so rapid and sudden 
that death takes place before relief can be given. It is, therefore, the 
part of prudence to interfere early and before the interference is made 
actually necessary by the defective breathing. Advantage should be 
taken of the opportunity afforded by the operation to reduce any dis- 
placement that may exist and that can be overcome by manipulation 
through the wound. 

Trachea. The symptoms of fracture of the trachea are similar to 
those of fracture of the larynx, except the local ones due to the dis- 
placements ; the diagnosis is difficult because of the lack of symptoms 
distinctive of the seat and character of the lesion. The prognosis is 
unfavorable, and the treatment has usually been insufficient to avert 
the fatal termination or relieve the suffering, because in the few 
recorded cases the seat of injury has been beyond reach by operation. 
The indication for treatment is to insert a tube into the trachea past 
the point of fracture so as to insure free breathing. 



CHAPTER XV. 

FRACTURES OF THE STERNUM. 

The sternum, formed originally of several pieces, has an irregular 
and uncertain development, only one feature of which needs here to 
be mentioned. The upper portion, the manubrium, may unite by 
ossification with the central portion, the body, at some time during 
adult life, and in such case a traumatic separation of the two portions 
is a fracture, not a dislocation. 

Fracture is rare, almost unknown, before the age of twenty years, 
and is frequently associated with other fractures, especially of the ribs 
and vertebrae. The fracture may be incomplete, multiple, transverse, 
oblique, or longitudinal. Of the first form there are but two recorded 
instances ; in both the infraction occupied the posterior surface of the 
bone at or near the junction of the lower and middle thirds and was 
accompanied by an abundant extravasation of blood into the anterior 
mediastinum. 

Of compound fractures, except such as were gunshot or stab wounds, 
there is but one example, reported by Duverney in 1751. A quarry- 
man, while at work lying upon his side, was caught under a heavy 
stone about five feet long which compressed his chest laterally with 
such force as to separate the middle portion of the sternum from the 
upper portion and force it through the skin. Death was immediate, 
by rupture of the heart and lungs. 

Of pure longitudinal fracture there is but one certain example, but 
there are two other cases in one of which there was a longitudinal frac- 
ture of the manubrium, and in the other of the body of the sternum 
associated with a transverse fracture at its upper end. The first case 
was that of a man who was overthrown and crushed by a falling wall ; 
in addition to numerous contusions, the sternum was broken longitu- 
dinally through its entire length, the right half being depressed 
from eight to ten lines below the level of the left half. There was 
profuse bloody expectoration and difficult breathing. Reduction was 
accomplished by drawing the right arm back and making forcible press- 
ure upon the middle of the sternal ribs of the right side and gentle 
pressure upon the left side. The patient recovered in six weeks. 

Cases of congenital fissure of the sternum have been mistaken for 
longitudinal fracture. 

Simple transverse fractures form the great majority of fractures of 
the sternum, and occupy most frequently the junction between the 
manubrium and the body of the bone or its immediate neighborhood — 
that is, the region of the second intercostal space ; next in frequency 
are fractures at or near the middle of the bone, corresponding to the 
184 



FRACTURES OF THE STERNUM. 



185 



third rib and the third intercostal space; they are rarely high in the 
manubrium and below the middle of the body, and very uncommon as 
separations of the ensiform appendix from the body. 

Fractures of the manubrium occur most commonly a short distance, 
two or three lines, above its lower border ; the periosteum sometimes 
remains untorn upon either the anterior or the posterior surface ; in 
some cases there has been no displacement, in others either the upper or 
the lower fragment has been displaced forward, and in one case there was 
angular displacement, the apex of the angle being directed backward. 
In several of the cases -the fracture was produced by muscular action, 
by straining during childbirth, or by the effort to raise a heavy weight 
with the teeth, the back being bent far back. In a large proportion 
of cases in which the lesion was produced by external violence there 
was also fracture of the ribs, clavicle, or vertebrae. 

Fig. 75. 




Fracture of the sternum. 



Fractures of the border have been observed in three instances, once 
in connection with fracture of the ribs, a scale of bone corresponding 
to the articulation with the first rib being broken off; a second time in 
connection with dislocation of the sternal end of the clavicle, the por- 
tion to which the sterno-cleido-mastoid was attached being torn off and 
drawn upward nearly half an inch ; and in a third case in connection 
with a transverse fracture lower down. 



186 



FRACTURES. 




Transverse fracture at or near the junction of the manubrium and 
body of the bone, and diastasis at this point, which is not always to be 
distinguished from fracture, are the commonest 
forms of injury. In the great majority of cases the 
lower fragment is displaced so as to lie in front of 
the upper one, and sometimes to override ; it is ex- 
ceptional for displacement to be absent or for the 
upper fragment to lie in front of the lower one. 

There is reason to think that the periosteum is 
almost invariably torn upon the anterior surface, 
but that it sometimes remains untorn behind, a 
fact which derives considerable importance from 
its bearing upon the escape of blood into the ante- 
rior mediastinum. One or both of the second pair 
of ribs usually remain attached to the manubrium. 
Out of a total of 105 cases of fracture of the 
sternum collected by Gurlt, 27 are described as 
partial or complete diastasis at the junction of the 
first and second portions, the character of the lesion 
having been determined by post-mortem examina- 
tion in fourteen of them. 

Fractures of the body of the sternum (Fig. 76) 
occur most frequently between the second and 
fourth costal cartilages, are usually transverse, but 
sometimes oblique laterally or from before back- 
ward. The displacements are the same as after 
fracture at the junction of the manubrium and 
sternum, and there is the same relative frequency of the projection of 
the lower fragment. 

Comminuted fracture of the body of the sternum has been rarely 
seen except in connection with gunshot and punctured wounds. Of 
triple fractures Gurlt found only two cases, and of double fractures 
only six, all of them associated with fracture of other bones, usually 
the ribs or vertebra?. 

Of fracture or diastasis of the ensiform appendix, Gurlt collected 
only four examples, and the list does not appear to have been increased 
by subsequent writers; one was a fracture, the other three diastases. 
The fracture was produced in a man sixty years old by a fall upon the 
sharp edge of a grain measure, and, when last examined, nine months 
after the accident, was still ununited, and crepitated on pressure, but 
caused no inconvenience. In the other three cases the prominent symp- 
tom was persistent vomiting, which in one lasted for two years, recurring 
every five or six days, and then ceased spontaneously ; in another it 
was cured by grasping the process between two fingers and bending it 
back into place ; and in the third, after it had lasted a month and 
death by exhaustion seemed imminent, it was instantly relieved by 
the reduction of the displacement, which was accomplished by in- 
serting a blunt hook into the abdominal cavity through an incision, 
and drawing the process forward. The patients were aged respectively 
twenty-eight, eighteen, and nineteen years. 



Transverse fracture 
of the body of the 
sternum. 



FRACTURES OF THE STEBNUM. 1X7 

The effusion of blood, which is observed after all fractures, may 
attain an especial importance after fracture of the sternum, by the 
pressure which it may exert upon the underlying heart. The blood, 
coming from the torn vessels of the bone and periosteum, makes its 
way forward into a region where it can do no harm if the periosteum 
on the posterior surface remains untorn ; but if this membrane shares 
in the injury, and especially if one of the internal mammary veins or 
arteries is ruptured, the blood makes its way into the anterior medias- 
tinum, and sometimes in sufficient amount to cause death promptly. 

Rupture of the pericardium, or of the heart, has been observed in a 
few cases; as has also probable laceration of the lung, evidenced by 
the appearance of subcutaneous emphysema or pneumothorax. 

Etiology. Fracture of the sternum may be produced either by mus- 
cular action or by external violence. 

There are four recorded cases in which the bone has been broken by 
straining during labor, and three in which the fracture has occurred 
during an effort to lift a heavy object. 

External violence acts either directly by a blow upon the breast, or 
indirectly by forcibly bending the body forward or backward, or pos- 
sibly by a combination of the two forms in the fall upon the body of 
a heavy object, or the passage across it of a loaded wagon, or, according 
to Lane, by depression of the shoulder acting through the clavicle and 
the upper ribs. It is not necessary that the force which acts directly 
should be very great to produce fracture ; it is sufficient for it to act 
upon a limited area, as in a fall upon a stone, or stick, or the edge or 
corner of a box. 

The violence which produces indirect fracture is, in most cases, a fall 
either upon the shoulders or buttocks, or with the back or breast across 
some fixed object, so that the trunk is bent sharply forward or back- 
ward ; in the one case the bone is broken by being bent forward, in the 
other by traction exerted through the muscular attachments at either 
end. 

Diagnosis. The diagnosis is readily made by the objective symp- 
toms — the displacement, mobility, and crepitus — and by the localized 
area of pain excited by pressure, change of position, and the more 
forcible respiratory acts. I have seen a few cases in which the only 
symptom was pain on pressure, with late ecchymosis. The examination 
of the bone must be made carefully in order, on the one hand, to avoid 
mistaking some irregularity of development for a traumatic displace- 
ment, and, on the other, not to overlook a second or third fracture, or 
even a single one in case there should be no displacement. In cases 
of supposed injury to the ensiform appendix the frequent irregularities 
in the shape, position, and mobility of that part must be borne in mind. 

The importance of the injury is by no means so great as the mor- 
tality of the recorded cases would indicate, for this mortality is largely 
due to associated lesions. Gurlt tabulated 98 cases with reference to 
this point, among others, and found that of 54 simple eases 4(> recov- 
ered and 8 died, while of 44 complicated eases, eases, that is, in which 
there was some severe associated injury, only 1 recovered and 4;> died. 
Of k 20 eases in which the fracture was certainly caused by direct vio- 



188 FRACTURES. 

lence, 15 recovered and 5 died, 3 of the latter being complicated 
cases. 

Course. The course in the uncomplicated cases is uneventful ; if pain 
and oppression are marked at first they soon diminish and disappear, as 
do also expectoration of blood, dyspnoea, and orthopncea. The principal 
danger is from pulmonary complications, especially in the old and 
alcoholic. In exceptional cases the local reaction may be great and 
may lead even to the formation of an abscess about the fracture. The 
pus may make its way to the surface between the fragments or on the 
sides, and if it collects upon the posterior surface and is discharged 
imperfectly through a small opening, the sinus may persist indefi- 
nitely, or the unnatural conditions may lead to extensive caries of the 
bone. Both conditions require treatment by active operative inter- 
ference. 

Usually repair takes place in from four to eight weeks, and by a 
bony callus. The persistence of a certain degree of displacement is 
not uncommon, and in some cases the deformity has been extreme. 

Failure of bony union has been observed in a few cases, but does 
not appear to have caused any disability beyond a temporary difficulty 
in abduction and adduction of the arms. 

Gunshot fractures may be penetrating or non-penetrating. A num- 
ber of illustrative cases of each kind are given in the Surgical History 
of the War of the Rebellion. The latter do not differ materially from 
compound fractures due to any other cause, but in the former the prog- 
nosis is rendered very grave by the associated lesions. 

Treatment. The first indication is to reduce such displacement as 
may exist. This is not always possible ; the most intelligently directed 
and persistently conducted efforts have sometimes failed. The usual 
method is direct pressure upon the projecting fragment, aided, espe- 
cially when there is overriding, by traction upon the two pieces. The 
traction must be made, in part at least, through the muscles attached 
to the ends of the bone, and is accomplished sometimes by resting the 
back upon some rather firm object, as a cushion or box, and bending 
the head and shoulders forcibly backward. At the same time the 
patient may be directed to take a full inspiration, and the surgeon 
presses downward against the upper edge of the lower fragment if that 
one, as is usual, projects, or he draws this fragment downward by 
taking hold of the projecting ribs that are attached to it. Various 
modifications of the plan have been employed, but all have the same 
fundamental idea, that of traction in opposite directions upon the frag- 
ments by forcible bending of the body backward. In one case reduc- 
tion was gradually effected in three days by keeping the patient recum- 
bent, with the head and shoulders thrown back. 

A number of operative methods have been proposed for use in those 
cases in which the displacement cannot be reduced by manipulation, 
such as to raise the depressed fragment by a sort of gimlet screwed 
into it, or by an elevator or blunt hook passed under it through an 
incision, or to cut away the projecting portion, or to press it back with 
a rod carried directly down to it through an incision. Most of these 
remain as suggestions that have not been put to the test. One case 



FRACTURES OF THE STERNUM. 1 89 

has been already mentioned in which the ensiform appendix was drawn 
forward successfully by means of a blunt hook passed into the per- 
itoneal cavity ; in another, of fracture at the upper part of the sternum 
with depression of the lower fragment, an incision was made with the 
intention of introducing a hook, but the pleural cavity was opened 
and the surgeon felt it necessary to close the wound immediately. In 
another the upper fragment was raised to the proper level by screwing 
a sort of gimlet into it and drawing it forward, but it afterward sank 
partly back again, and a second attempt to raise it was defeated by the 
tearing of the screw. 

Unless the displacement is actually causing dangerous or distressing 
symptoms these methods of removing it by operation are hardly justi- 
fiable, because they carry with them risks that should not be lightly 
run. 

The subsequent treatment consists in immobilization of the chest, 
and, if necessary, in the use of measures to allay local inflammation 
and to prevent coughing. A convenient dressing is a broad flannel 
bandage pinned tightly about the chest after forced expiration, or bands 
of adhesive plaster extending from side to side across the front of the 
chest and covering the entire length of the sternum. 

If the formation of pus behind the bone is recognized or suspected 
it should be promptly sought for and evacuated by cutting through the 
bone at the seat of fracture. 



CHAPTER XVI. 

FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

Fractures of the Ribs. 

These are among the commonest of all fractures, more common in 
men than in women, and almost unknown (or unrecognized) in infancy 
and childhood ; probably many cases pass unrecognized, and the fre- 
quency is even greater than the statistics show. 

Pathology. The fracture may be partial or complete, simple or com- 
pound, single or multiple. Partial fractures may be constituted either 
by a fissure involving only one of the borders of the rib and, perhaps, 
separating entirely a longer or shorter fragment of that border, or by 
an infraction. The former is very uncommon. 

Complete fractures may be transverse, oblique, irregular, or multiple, 
and may be limited to a single rib, or may involve all the true ones on 
one side, and in some cases even many on both sides. The central 
ribs are the ones most frequently broken. Fracture of the twelfth is 
very rare ; Gurlt could find only two recorded cases, the causes being 
a fall against the edge of a step and a table respectively. I saw one 
at the Hudson Street Hospital in 1896, in a man, fifty years old, who 
had been caught about the waist in the loop of a hawser. He died a 
few days later of coincident rupture of the large intestine ; the twelfth 
rib was broken obliquely at its centre. For another case, see Chapter 
XL., Dislocation of Head or Rib. In 1905 I saw another, a sailor 
carried by a wave against the corner of a hatch. 

Fracture of the first rib was formerly thought to be almost equally 
rare, but the observations of Lane l and Marsh 2 indicate that fracture 
of it or its cartilage may be rather common. Lane found four speci- 
mens in a series of 200 bodies in the dissecting-room, and Marsh saw 
four cases in six months' hospital service. According to Lane this rib 
is easily broken by forcible depression of the shoulder acting by direct 
pressure of the clavicle. The symptom is said to be pain behind the 
upper part of the sternum on lifting with the corresponding hand. 

The fracture of a rib may occupy any part of it, but is most fre- 
quent on the side and anterior half. The periosteum may remain 
untorn, and the fragments preserve their relations to each other, or 
they may form a re-entrant or a salient angle, or override each other. 
If several ribs are broken at the same time and forced inward the 
depression may remain both broad and deep. Overriding of the frag- 
ments is impossible unless several ribs are broken at the same time, 
for the muscular and fibrous attachments of the adjoining ones hold the 
fragments in place, and the ribs above and below act as splints to pre- 

1 Lane : British Medical Journal, 1887, vol. ii. p. 119. and Guy's Hospital lieports, 1886, 
p. 429. 2 Marsh : Lancet, June 30, 1888. 

190 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 191 

vent shortening. In double or multiple fracture of one or several ribs 
the intermediate piece or pieces may be so loosened that they move in 
and out with every inspiration. 

In compound fractures the wound of the soft parts is rarely, if ever, 
caused by the projection of the broken end of the rib, but always by 
the object which produced the fracture. 

The complications include injuries to the muscles, which are rarely 
important, to the intercostal arteries, and to the thoracic and abdom- 
inal viscera. The intercostal arteries are rarely seriously injured, 
although moderate hemothorax is not uncommon after fracture of the 
middle third, especially of the sixth to the ninth ribs. Fatal hemor- 
rhage into the pleural cavity has occurred in a few cases, even after 
fracture of a single rib and by slight violence, and a case of traumatic 
aneurysm has been reported (see p. 79). 

A wound of the pleura and of the lungs is a rather common com- 
plication, and is generally caused by the sharp end of a fragment, but 
in some cases fatal injury of the lung has been caused by the crushing 
effect of the external violence acting through the, perhaps unbroken, 
ribs; the thorax is compressed by the force, and the lung is put upon 
the stretch in such a manner that it is actually torn, not perforated by 
the bone. The consequences of the wound vary with its size and with 
the relations existing between the lung and the thoracic wall. If these 
latter are normal — that is, if the lung is not adherent at the wounded 
part — air and blood escape more or less freely into the pleural cavity, 
and the lung collapses ; if, on the other hand, the lung is adherent, 
the escaping air makes its way into the meshes of the connective tis- 
sue, and may spread through the mediastinum, under the pericardium 
and pleura, and into the interlobular tissue of the lung itself and the 
subcutaneous tissue on the surface of the body. Emphysema of the 
surface may be produced also when the lung is not adherent ; the air 
which has escaped into and filled the pleural cavity is forced by the 
contraction of the chest during expiration out through the opening at 
the fracture, and its place is supplied at the next inspiration by fresh 
air drawn in through the wound of the lung, and thus a small quan- 
tity is pumped into the outer cellular tissue at each respiration, and 
this will continue until one or the other opening is closed by a clot or 
exudate or a change in the relations of its walls. 

Wounds of the heart are much rarer, and even more dangerous. 
Gurlt collected six cases, in only four of which the wound of the heart 
appears to have been caused by the broken rib ; in the other two it 
appears to have been caused by the compression of the heart between 
the anterior chest-wall and the vertebral column, for the pericardium 
was untorn. 

Etiology, Fractures of the ribs may be caused by muscular action 
or by external violence. Of muscular action the most common form 
by far is coughing; others are sneezing, lifting a heavy object, even 
turning in bed. The lower ribs, especially the eleventh, arc the ones 
most frequently broken in this way, but it has happened to the second, 
fourth, fifth, and sixth. It is much more common on the left than on 
the right side. (Sec forty cases collected by Tunis in University Med- 



192 FRACTURES. 

ical Magazine, November, 1890, and thirteen personal cases by Cliel- 
monski in Centralbl. f. Chir., 1901, p. 1188.) The so-called sponta- 
neous fractures are observed almost exclusively in the insane, whose 
bones are frequently very soft. 

By far the most common cause of fracture is external violence, by 
a blow, fall, or excessive pressure. The fracture may be direct or 
indirect, but it is not often easy to distinguish between these two 
varieties. In indirect fractures caused by pressure upon or near the 
sternal ends of the ribs the fracture is found most frequently in either the 
anterior or the posterior third, and the point of greatest frequency seems to 
be very near that at which the force is received, an inch or two on the 
outer side of the sternal end of the bone. Double or triple fractures of 
one or more adjoining ribs may apparently be caused in either of two 
ways : Extreme violence acting at one point breaks the rib at that point 
by direct pressure, and then depressing the broken ends breaks the bone 
again at a distance indirectly on one or both sides ; or, the force acting 
more broadly, breaks the bone simultaneously at a point on each side. 

Symptoms. The symptoms of fracture of a rib in the less severe 
cases are likely to be obscure. The breathing is shallow and some- 
times catching through pain or fear of pain, and occasionally there is 
very troublesome reflex cough. Pain is provoked by pressure, inspi- 
ration, coughing, sneezing, and certain movements of the body; its 
diagnostic value comes from its limitation to one point under the dif- 
ferent causes and especially when pressure is made on the affected rib 
at a distance. 

Abnormal mobility is sometimes present, but the elasticity and 
mobility of the ribs make its recognition uncertain. It may sometimes 
be made out by placing a finger on each side of the suspected fracture, 
and pressing alternately with one and the other. The same manipula- 
tion may produce crepitus, but usually this is more readily recognized 
by placing the hand flat upon the chest, and pressing slightly at dif- 
ferent points, or asking the patient to cough or draw a long breath. 
It may also be heard sometimes on auscultation of the chest in the 
usual manner, and may be accompanied after a day or two by a pleu- 
ritic friction sound, the result of a pleurisy excited by the trauma- 
tism, and usually limited in area to its immediate neighborhood. It 
is not uncommon for the patient himself to recognize the crepitus. 
Emphysema is, in itself, a very positive sign of injury to the lung and 
of fracture of a rib if there is no penetrating wound to account for it 
otherwise. Pneumothorax, or hemorrhage into the pleural cavity from 
a lacerated lung or an intercostal artery may be present in any of the 
severer cases ; and bloody expectoration, which also points toward 
fracture, is often present even in slight cases, and is not infrequently 
absent in grave ones. 

The symptoms of partial fracture or infraction are seldom definite 
enough to permit a positive diagnosis. 

The course of a simple uncomplicated fracture is usually quite 
uneventful ; the patient remains quiet, sometimes keeping his bed, and 
breathes carefully and superficially to avoid pain ; after two or three 
weeks he finds these precautions unnecessary, and the surgeon finds on 
examination that the local tenderness has disappeared, and that crep- 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 



Fig. 77. 



itus and mobility can no longer be detected. Union by a bony callus 
takes place almost invariably, notwithstanding the defective immobili- 
zation of the parts, but, as a consequence of the latter, the callus is 
likely to be large, and, when two or more ribs have been broken, to 
unite the adjoining ones by a bridge of new formation. Solidity is 
given at first by an ensheathing callus, and the union between the 
fractured surfaces, even when they are in apposition, may remain 
fibrous for several months. Failure of union is rare. 

Displacement upward or downward of a fragment may lead to its 
union with the adjoining rib, or to the formation of a lateral joint 
between them, as in the next following case; or, if adjoining ribs are 
displaced in opposite directions, a gap may be left between them which 
may lead to hernia of the lung, as in a case which is recorded in the 
Gazette 3Iedwale de Paris, 1832, p. 465, and pictured in Cruveilhier's 
Atlas d' 'Anatomie Pathologique, a gap in the right side in front between 
the first and fourth ribs, four inches long and two inches wide. The 
patient had survived the accident about 
forty years. 

The course and symptoms in the severer 
cases vary with the degree and character 
of the complications which give them 
their gravity. Emphysema may be slight 
and transitory, or it may continue for days 
and spread over a large portion of the 
surface of the body. If the air escapes 
into the cavity of the chest, or if the frac- 
ture is compound with a penetrating 
wound, the resultant dyspnoea and oppres- 
sion may be extreme, and the physical 
signs of pneumothorax will be found upon 
examination. If, in addition to the escape 
of air, there is also free hemorrhage into 
the chest from the torn lung or an inter- 
costal artery, the physical signs will be 
correspondingly modified. Extreme dysp- 
noea, due to congestion of the lung follow- 
ing promptly upon the injury, is not un- 
common, and pneumonia occasionally results and leads to a fatal 
termination in the old and feeble. 

I have observed in half a dozen cases of severe compression of the 
chest with fracture or dislocation of ribs or, more commonly, costal 
cartilages, a peculiar dusky discoloration of the skin of the face, neck, 
and upper part of the chest, together with marked subconjunctival bul- 
bar ecchymosis nearly limited to the interpalpebral space. The dis- 
coloration does not disappear on pressure and is apparently due to the 
coloring-matter of the blood, possibly through innumerable minute 
capillary extravasations. It appears immediately, is evidently due to 
the compression of the chest, and disappears slowly. 1 

Legros Clark 2 claims that serious functional derangement, without 




Fracture of ribs, with excessive 
callus. (V. Bergmann.) 



13 



1 New York Medical Journal, March 1, 1890. 
8 Clark: Diagnosis ol' Visceral Lesions, j>. 213. 



194 FRACTURES. 

organic lesion of the lung, may result from contusion or concussion of 
the chest, that it may be transient or may be followed by inflammation, 
local or general, of the affected lung, and that it is sometimes observed 
in the lung on the side opposite that which has sustained the injury. 

Prognosis. The prognosis depends largely upon the complications. 
Simple fractures without important complications do well, as a rule; 
the exceptions are found mainly in the old and feeble, whose lives may 
be endangered by congestion of the lungs, pneumonia, or pleurisy. 
Cases complicated by wound of the heart or pericardium are usually 
promptly fatal. Wounds of the lungs are serious, but there are many 
instances of recovery even in cases where the laceration of the lung 
was probably extensive and accompanied a fracture that was in itself 
severe. 

Treatment. The indications for treatment are to reduce any displace- 
ment that threatens to produce a complication or that causes pain, to 
immobilize the chest-wall, and to relieve or prevent pulmonary inflam- 
mation or congestion. 

Outward angular displacemont may be corrected by pressure upon 
the projecting angle, and inward angular displacement may sometimes 
be corrected, when the broken surfaces are still in contact and the frac- 
ture is situated near the middle of the rib, by pressing the sternum 
backward and thus springing the bone out. If the fragments have 
overriden this manoeuvre is worse than useless, for it can only increase 
the displacement. Relief may also be obtained by making the patient 
strain or draw full deep breaths. Ravaton relieved the pain and cor- 
rected the displacement in one case by suspending the patient upon two 
rods passed under his axillae. 

When the displacement was greater and one of the fragments was 
pressed inward Malgaigne ingeniously made use of the other to elevate 
it, pressing it in until the ends met and became locked together by the 
irregularities of their broken surfaces so that the elasticity of the second 
should serve to raise the first. 

For the elevation or removal of a depressed fragment by operation 
a number of methods have been proposed, but very few instances are 
known of the use of any of them. If such elevation should seem 
necessary, and if approach through an incision were deemed inadvisable 
because of the risk of the admission of air to the pleural cavity, the 
old suggestion of raising the bone by means of a hook passed through 
the skin and behind the upper border of the bone might be used. 

Immobilization of the chest is best effected by surrounding it with 
a broad, snugly drawn piece of adhesive plaster, or with two or three 
narrower strips. The guide to the amount of pressure is the comfort 
of the patient. Malgaigne preferred a bandage three or four inches 
wide and long enough to pass once and a half around the chest, and 
he did not place it lower than the ensiform appendix, believing it to 
be sufficient, whichever ribs might be broken, to restrain the move- 
ments of the middle ones. When a circular bandage cannot be borne 
he recommends that a long narrow strip of plaster should be carried 
from the anterior end of the seventh rib on the right side, for example, 
across the front of the chest, under the left arm and across the back to 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 195 

and over the right shoulder, thence again across the chest in front and 
around the left side and back to end at the crest of the right ilium. 
This immobilizes the left side of the chest very effectually and leaves 
the right side free. He suggests that in addition the arm should be 
fixed to the side. 

The pressure of a bandage is useful also to prevent the spread of 
emphysema. This complication seldom requires any more active treat- 
ment, although scarifications have been made or the air drawn off through 
a trocar. If either method is used the instrument should be applied 
at a distance from the fracture. The more dangerous variety of 
emphysema, that in which the air makes its way into the mediastinum 
and the interlobular tissue of the lung, is not amenable to operative, 
treatment. 

In pneumothorax it may be desirable to draw off the air through an 
aspirating needle or a canula in order to relieve the pressure, and if 
blood accumulates within the pleural cavity in quantities sufficiently 
large to endanger life by interference with the action of the heart and 
either or both lungs, it may become necessary to remove it by aspira- 
tion or incision, but the indications should be very plain before the 
surgeon decides to interfere in this manner, since the removal of the 
blood and the relief of pressure may only lead to a return of the bleed- 
ing. Persistent internal hemorrhage can be treated only by indirect 
measures, because its source cannot be recognized, and, if recognized, 
probably could not be reached, It has been found useful to constrict 
the thighs circularly at the groin with rubber tubing or a roller-bandage 
just sufficiently to arrest the venous current ; this withdraws a consid- 
erable amount of blood temporarily from circulation and acts as a 
venesection. It sometimes arrests bleeding instantly. 

When life is threatened by pulmonary engorgement with extreme 
dyspnoea, blood should be taken from the arm immediately and freely, 
and the bleeding should be repeated if the symptoms reappear. The 
older records are full of cases showing the benefit of this practice, and, 
among modern surgeons, Mr. Bryant recommends it unhesitatingly and 
forcibly. He says : " Bleed with no sparing hand. . . . When relief 
has been obtained arrest the flow immediately, as syncope can only 
do harm/ 7 then follow with antimony. 

Fractures of the Costal Cartilages. 

The first mention made of this lesion appears to have been by 
Zwinger in 1698, and it is not again referred to in medical literature 
until 1805, when Lobstein, at Strasburg, and in 1806 Magendie, at 
Paris, each described it with cases. Additional observations were made 
by Delpech, Sir Astley Cooper, and Velpeau, and in 1841 Malgaigne l 
published a paper upon the subject which, six years afterward, he 
reproduced in part in his book on fractures. Since then but little 
work has been done upon the subject, most writers contenting them- 
selves with reproducing in substance Malgaigne's chapter, luirlt col- 
lected more than thirty cases for the chapter upon it in his book on 

1 Malgaigne: Bulletins de Therapeutique, 1841, p, 227. 



196 FRACTURES. 

fractures, and Paulet, 1 who appears not to have known of Gurlt's 
work, gives fourteen cases which he obtained by a partial search through 
French periodical literature, only four of which are mentioned by 
Gurlt. Bourneville 2 (1880) and Pozzi 3 (1888) raised the list to seventy- 
nine cases. I have seen two or three. 

Fractures occur much more frequently at or near the junction of the 
cartilage and rib than at any other point, and more frequently in the 
seventh and eighth ribs than in any other. The fracture may be double, 
and may involve several cartilages on one side or on both. All the 
recorded fractures have been complete with the exception of one case ; 
they have been perpendicular to the long axis of the cartilage, or very 
slightly oblique, and the surface has always been smooth, without ser- 
rations or splinters. 

It is probable that persons advanced in life are more liable to this 
fracture than the young, because of the calcification or ossification of 
the cartilages, but it has occurred in young men (seventeen years) and 
even in a child seven years old. 

Displacement has been absent in a very few cases ; in most it takes 
place in the antero-posterior direction, and in some the fragments have 
overriden in the direction of the long axis of the rib. This latter 
form, probably, is possible only in the longer and more curved ribs, or 
when several adjoining ones are broken. The separation in either of 
these two directions may amount to as much as an inch, but is rarely 
so great. Either fragment may lie in front of the other, although the 
costal fragment projects more frequently than the sternal one ; the dis- 
placement, however, appears to depend entirely upon the direction of 
the fracturing force and upon the position occupied by the patient. 

No instance of a compound fracture of a costal cartilage is on record, 
and the complications are less frequent and, as a rule, less serious than 
those accompanying fractures of the ribs. In some cases wdiere the 
violence has been extreme and many cartilages have been broken fatal 
injury has been done at the same time to the heart or great vessels, but 
not by the penetration of one of the fragments ; the viscera are crushed 
or torn by the continued action of the force after the wall of the chest 
has yielded under it. 

Hernia of the lung has been observed in three cases, one after frac- 
ture of the third and fourth cartilages and rupture of the intercostal 
muscles by the fall of a heavy weight, the second, a double one, after 
fracture or diastasis due to paroxysms of coughing, and the third, 
observed by Legros Clark 4 after a blow received from the shaft of some 
vehicle. In this one the cartilage of the second rib was driven in, 
creating a gap through which a tumor as large as the fist appeared at 
each inspiration and disappeared at each expiration, leaving a depres- 
sion capable of containing at least two ounces of liquid. Recovery in 
three weeks, the gap persisting but " evidently occupied by some 
plastic deposit." 

1 Paulet : Diet. Encyclopedique, First Series, vol. xxi., art. Cotes, 1878. 

2 Bourneville: Progres Med., 1880. 3 Pozzi : Ibid., October 20, 1888. 
4 Legros Clark : Loc. cit., p. 206. 



FRACTURES OF THE RIBS AND 1HEIR CARTILAGES. 197 

In seven cases the fracture has been produced by muscular action, 
either an excessive effort, as to avoid a fall or to throw a heavy object, 
or coughing or sneezing. Thus Broca l reported the case of a porter 
at the market who having placed a sack of peas upon his shoulder 
asked a comrade to add another to it. The latter threw the second sac 
heavily upon him, and in the effort to avoid a fall under the weight he 
fractured the cartilages of the sixth, seventh, and eighth ribs on the 
right side at points seven or eight centimetres from the median line. 

Fractures by external violence may be direct or indirect. Gurlt, 
thinks the indirect fractures take place at or near the costo-chondral 
junction, the force acting upon the rib itself in such manner as to spring 
its anterior end outward, while in the direct fractures the force is 
exerted upon a restricted area of the cartilage itself, as in a fall upon 
the edge of a tub or step, the blow of a fist, the kick of a horse. 

The symptoms are local pain and deformity. Crepitus and abnormal 
mobility are not often recognizable, but if displacement is present it can 
usually be made out by following the outline of the rib and cartilage 
with the finger and by observing that it can be increased or diminished 
by pressure upon one or the other fragment. It may not be easy in 
some cases to say whether the fracture involves the rib or the cartilage 
and in others whether it is a fracture of the cartilage or a dislocation 
of its sternal or costal end, but the question has no practical impor- 
tance. 

The prognosis, independent of complications, is favorable, and the 
fracture may be expected to unite in three or four weeks. Our knowl- 
edge of the mode of repair has been obtained partly by experimentation 
and partly by examination of specimens. When the fragments remain 
end to end and the fractured surfaces are more or less completely in con- 
tact, a fibrous band unites them, and the union is strengthened by an 
external ring of spongy bone. In a specimen obtained by Basserau 2 
and examined microscopically by Malassez, and in one reported by 
Pozzi, 3 it was found that the central band was partly cartilaginous, 
and it is asserted that in other specimens points of ossification have 
been found. 

Fig. 78. Fig. 79. 





Repair of fracture of a costal cartilage. (Guri/t.) Repair of fracture of a costal cartilago. 

When the fragments override, they take, so for at least as the broken 
ends are concerned, little or no part in the repair. Union is accom- 
plished by an intermediate band which is at first fibrous or cartilaginous 
and may become bony (Fig. 78), or if the fragments are in contact 

1 Broca: Quoted by Paulet, loc. cit., p. 83. '-' Basserau : Paulet, loo. oit., p. B8 

:i Pozzi : Loc. cit. 



198 FkACTURES. 

the new bone forms on the sides and the ends (Fig. 79), and in both 
cases it envelopes the pieces more or less completely like a ring. This 
ring originates apparently in the perichondrium, and its ossification is 
the final result of the formative irritation created by the traumatism, 
and is analogous to the ossification seen so constantly not only in carti- 
lage which would normally be transformed into bone, but also in others, 
such as that of the larynx, whose normal evolution does not include 
that change. 

Treatment. The treatment is similar to that of fracture of the ribs : 
reduction of a displacement if necessary and possible, and immobiliza- 
tion. The former must be accomplished, if at all, by placing the 
patient upon the opposite side or upon his back, by drawing the shoul- 
ders back, or by deep inspirations ; the latter by a body bandage, strips 
of adhesive plaster, or, following Malgaigne's example, by a hernial 
truss so placed as to restrain the fragment that tends to project. 



CHAPTER XVII. 

FRACTURES OF THE CLAVICLE. 

Fracture of the clavicle is a common injury and is especially 
frequent in childhood, taking the place at that age, as was pointed out 
by Kronlein, of dislocation of the shoulder by direct violence later in 
life. That is, a fall upon the shoulder breaks the clavicle of a child 
but dislocates the shoulder of an adult. 

Pathology. 

It has been found convenient by most modern authors for the pur- 
poses of study and description to divide the fractures into three groups, 
according as they occupy the inner, middle, or outer third of the bone. 
The average length of the clavicle is six inches, and this division into 
thirds of about two inches each corresponds to anatomical differences 
of considerable clinical importance. To the flattened outer third are 
attached the trapezius and deltoid muscles and the strong coraco-clavic- 
ular ligament binding it to the coracoid process, the inner fasciculus of 
which, known as the coracoid ligament, marks the inner limit of this 
portion, and can sometimes be readily felt upon the living body. The 
dividing line between the inner and middle thirds is not so definitely 
marked anatomically, it corresponds approximately to the point where 
the clavicle crosses the lower or outer edge of the first rib. The inner 
third is attached to the sternum by the sterno-clavicular ligaments, and 
to the cartilage of the first rib by the costo-clavicular or rhomboid 
ligament. To its upper border is attached the sterno-cleido-mastoid 
muscle, to its lower the pectoralis major. 

Since the outer third is broadly attached by ligaments to the scapula 
it is apparent that after fracture of the bone in the inner or middle 
third the outer fragment will not be able to change its relations to the 
scapula materially, and that its displacement, therefore, will be gov- 
erned by the change of position of the latter, by its sinking inward 
and forward to the side of the chest in consequence of the loss of its 
anterior support. 

The outer portion of the middle third is by far the most common 
seat of fractures observed clinically, but Lane's 1 observations in the 
dissectiug-room and his experiments indicate that fractures of the outer 
third may be very frequent and usually unrecognized. 

The fracture may be partial or complete, single or multiple, simple 
or compound ; the most frequent form is simple complete fracture. 
Compound fracture is so rare that Gurlt says he could find only four 
examples of it, and Hamilton, who gives the same four eases, says he 
had never met witli an example. I have seen one : A laborer was 

1 Lane: Guy's Hospital Reports, L886, vol. xliii. 

199 



200 FRACTURES. 

struck by a falling stone upon the shoulder and sustained a fracture of 
the right clavicle at a point nearly two inches from the sternal end of 
the bone. The line of fracture was oblique from above downward and 
inward. A large ragged wound extended backward across the clavicle 
and shoulder, in which some of the divided fibres of the trapezius could 
be seen. The outer end of the inner fragment was directed sharply 
upward, the outer fragment lying below and a little distance from it. 
The wound healed almost entirely in about six weeks, but when last 
seen there was still a sinus over the end of the inner fragment through 
which a probe could be passed to the bone. 

Incomplete or partial fracture is, according to Hamilton, who gave 
much attention to this variety, very common. He thinks that 34 
of the 157 fractures of the clavicle recorded by him l were partial 
fractures, and says that at least eleven of these were immediately and 
spontaneously restored to their natural axes. The symptoms accepted 
for this diagnosis are the history of a fall upon the shoulder, or at least 
indirect violence, the youth of the patient, a swelling upon the upper 
surface and front or rear border of the middle third of the bone appear- 
ing within two or three days after the accident, possibly a change in 
the axis of the bone, and possibly ability to straighten it with slight 
crepitus. 

1. Complete fracture of the middle third may be oblique or transverse, 
the former variety being found most commonly in adults, the latter in 
children. The line of an oblique fracture usually runs inward and 
downward or backward, but may take any other direction and may be 
nearly transverse, or extremely oblique (Fig. 80), or practically longi- 

Fig. 80. 



Oblique fracture of the clavicle. 

tudinal, as in a case observed bv Chassaignac and mentioned by Polail- 
lon, 2 in which the fracture ran from the centre of the acromial end to a 
point just external to the sterno-clavicular articulation, dividing the 
bone into two longitudinal halves. Multiple and comminuted fractures 
are rare. When the fracture is multiple or doubly the intermediate 
fragment is likely to occupy a very irregular position. 

The most common displacements are produced by the falling for- 
ward, downward, and inward of the shoulder, the consequence of the 
loss of support normally furnished by the clavicle, and depend some- 
what upon the direction of the line of fracture. The commonest form 
is that in which the sternal fragment is drawm upward by the sterno- 
cleidomastoid muscle or pushed upward by the outer fragment, which 

1 Hamilton : Fractures and Dislocations, 6th ed., p. 90. 

2 Polaillon : Diet. Encyclopedique, art. Clavicule, p. 682. 



FRACTURES OF THE CLAVICLE. 201 

is displaced inward along the under or anterior surface of the other 
and has at the same time changed its direction somewhat by the sink- 
ing of its acromial end. The shortening may be very notable, nearly 
one-third of the entire length of the bone in a specimen mentioned by 
Malgaigne. Another form is found where the line of fracture is such 
that the fragments do not readily leave each other, and the broken 
ends are displaced together upward and backward by the falling in 
of the shoulders so that the bone forms an angle at the seat of fracture. 
In some exceptional cases the outer fragment has lain upon the upper 
or posterior surface of the inner fragment. Malgaigne 1 says this 
variety was mentioned by Hippocrates, and that he himself saw one, 
but only one, example of it. Under these circumstances the sternal 
fragment is held down instead of being pushed up by the other one, 
and the displacement is mainly in the direction of the latter, the inner 
end of which is turned upward, forming a projection at the seat of 
fracture. 

Fig. 81. 




Fracture of the clavicle. Union with extreme displacement. 
Fig. 82. 




Fracture of the clavicle. 

In transverse fractures the broken surfaces seldom leave each other, 
and the only displacements possible are in thickness and direction, the 
lateral and angular. The latter is the one usually seen, the angle 
being directed, for reasons that have been already stated, upward and 
backward. 

The most common and persistent cause of these displacements is 
undoubtedly the tendency of the scapula and shoulder to fall forward 
and inward upon the chest, but it is aided largely in the first place by 
the fracturing force which continues to act after the bone has yielded 
to it. Thus, in a foil upon the shoulder or the outstretched hand, the 
clavicle breaks by the exaggeration of its normal curves, and as the 
direction of the line of fracture is usually downward and inward the 
outer fragment is forced inward on the under side of the other and 
necessarily turns the outer end of the latter upward. 

2. Fracture of the Outer Third. This variety is next in frequency to 
the preceding, and may be produced by direct or indirect violence. 
The direction of the line of fracture is more commonly transverse than 
1 Malgaigne: Loc. cit., p. 468. 



202 FRACTURES. 

oblique. The degree of displacement varies greatly in different cases, 
being very notable in some and slight or entirely absent in others. 

When displacement exists it is usually an angular one, the apex of 
the angle being directed backward. In some specimens 1 bony union 
has taken place between the clavicle and the scapula, presumably by 
ossification of the coraco-clavicular ligament. It is in the form of a 
prop extending from the under side of the clavicle to the base of the 
coracoid process, and sometimes to the notch of the scapula, and 
usually convex posteriorly. 

Fig. 83.. 




Fracture of the clavicle, outer third. Extreme angular displacement. (R. W. Smith.) 

When the fracture is external to the trapezoid ligament — that is, 
when it lies within the outer inch of the bone — angular displacement is 
the rule, the outer fragment turning forward and inward until its axis 
is at right angles with that of the inner fragment ; sometimes its broken 
surface lies against the anterior border of the inner one, and sometimes 
the outer fragment lies under the inner one. Malgaigne describes a 
case in which, after fracture within half an inch of the articular sur- 
face, the inner fragment was elevated an inch above the other, and 
there was shortening of nearly half an inch ; the appearance, in short, 
was that of a dislocation upward of the acromial end of the clavicle. 

3. Fracture of the Inner Third. The older division, which was into 
fractures of the body and fractures of the outer end, took no special 
notice of this variety which received its first separate description from 
Malgaigne. It is the least common of the three ; Delens, 2 who wrote 
the first formal article upon the subject, collected twenty-eight cases, to 
which Polaillon two years later added three. I have seen one caused 
by a direct blow with a baseball. The fracture may occupy any point 
in the division, and is more often oblique than transverse. It was 
asserted at first that the displacement did not occur if the fracture was 
within the region of the attachment of the costo-clavicular ligament, 
but the contrary has since been proved ; displacement may take place 
in any direction, but the commonest one is downward and forward of 
the inner end of the outer fragment, or of the adjoining ends of both 
fragments if they do not separate from each other. Polaillon attributes 
the principal part in the production of this displacement to the action 

1 Smith : Dublin Jonrn. Med. Sci., 1842, p. 478, and Fractures in the Vicinity of Joints, 
p. 212. 

2 Delens : Archives Generates de Med., 1873, vol. i. p. 529. 



FRACTURES OF THE CLAVICLE. 203 

of the pectoral and deltoid muscles upon the outer fragment, and finds 
support for his opinion in the fact that this displacement has always 
been observed after fracture by muscular action ; and as in this variety 
the fracture is usually near the inner articular surface, in a region, 
that is, where displacement after fracture by other causes is slight or 
absent, the argument is not without weight, although the obliquity of 
the line of fracture in such cases as that represented in Fig. 84 cannot 
be entirely foreign to the direction and degree of the displacement. 
When the fracture is transverse the lateral displacement may be slight 
or entirely absent and the periosteum may remain untorn. Longitu- 
dinal fracture with comminution was seen in one case, and Hamilton 
reports another in which the line ran from the articulation upward and 
outward for one and a half inches. The fragments overlapped three- 
fourths of an inch and were firmly united. In two cases the end of 
the outer fragment lay underneath the inner one and both were directed 
upward and backward. The outer end of the inner fragment is acted 
upon more strongly by the sterno-cleido-mastoid muscle than by any 
other, the effect of which is to draw it upward, and this effect is 
increased by the pressure of the outer fragment when that is forced in 
front of and below the other, so that whenever the two fractured sur- 
faces leave each other the inner fragment is likely to incline upward. 

Fig. 84. 




Fracture of the clavicle, inner third. (Gurlt.) 

Multiple Fractures. But few cases are recorded in which the bone 
has been broken in two or more places ; in some the fracture was by 
direct, in others by indirect, violence. Both fractures have been found 
in the middle third, but more commonly they occupy different thirds. 
When one fracture has been in the acromial, and the other in the inner 
or middle third, the intermediate piece has not shown much displace- 
ment, and each fracture has followed the usual course of a single one ; 
but when the fractures have been within or close to the limits of the 
middle third, the displacement has been very notable. 

Complications. Complications of fracture of the clavicle consist in 
injuries to the vessels, nerves, and lungs, and are exceedinglv rare, 
excluding gunshot wounds in which the complications are produced by 
the ball and not by the fractured bone. Taylor l reports a case of 
meurism of the subclavian artery and quotes another seen by Heath. 
Gallois and Piollet 2 report a case of arterio-venous aneurism (sub- 
clavian artery) and collected three others. Dupuytren speaks in a 

1 Taylor : Annals of Surg., 1903, p. 638. 

2 Gallois ami Piollet : Rev. do Chir.. 1901, 



204 FRACTURES. 

lecture of having seen two or three cases of aneurism following fracture 
of the clavicle, a~nd Jacquemiev gives a case observed by Blandin, of 
an aneurism of the acromial branch of the acromio-thoracic artery fol- 
lowing fracture by direct violence. Taylor l reports a case of aneurism 
of the subclavian caused by a splinter from the fractured clavicle and 
quotes 3 others by Heath, 2 Boulby, 3 and Twyman. 4 Taylor's recovered 
after operation. Meinhold 5 reports a case of gradual interruption of 
the current in the subclavian artery, becoming complete three and a 
half months after fracture in the middle by direct violence, healing with 
angular displacement ; relieved by resection of the angle. In a case 
reported by Fisk 6 of rupture of the subclavian and of four of the roots 
of the brachial plexus, with a subperiosteal fracture of the clavicle 
without displacement, by the fall of a heavy piece of iron upon the 
patient's shoulder, the fracture seems to have been an unimportant, 
non-causative incident, and the artery and nerves to have been torn by 
extreme depression of the shoulder. ( Cf. similar rupture of the nerves 
in Flaubert's case quoted in Chapter XXXIV., Emphysema of Cel- 
lular Tissue.) 

A few cases are reported of injury to the subclavian or internal jug- 
ular vein, in some of which the diagnosis was verified by autopsy. 
(See First Edition and Taylor, above quoted.) 

In the museum of St. George's Hospital is a specimen in which the 
fractured end of the bone was driven through the internal jugular vein. 
A man 7 fifty-nine years old broke the right clavicle in the middle 
third by a fall upon the shoulder. The fracture was very oblique from 
without inward and backward, and the vein was torn completely across 
by the outer fragment. The artery and nerves Avere not injured. 

Fifteen cases 8 have been reported in which symptoms indicating 
injury to the brachial plexus have appeared immediately or after an in- 
terval. In most of those in which they appeared promptly the causa- 
tive violence was great and the displacement of the fragments marked, 
but in mine there was no displacement. In one (Yelpeau) extensive 
subcutaneous emphysema showed injury to the lung, and fracture of no 
rib could be detected. In two (Earle, Stimson) there was paralysis of 
the scapular muscles supplied by the supi^a-scapular nerve which leaves 
the plexus above the clavicle. In two (Davis, Mauclaire) the displace- 
ment was corrected by operation with relief of symptoms, and in one 
(Poir.ier) the arm was amputated because of the pain. In six cases 
(Hassler, Sieur, Delens, Polaillon, Lequyer, McCosh) the symptoms 
appeared late ; they were due to excessive callus in the first-named five 
and to a cicatrix involving the plexus in the last ; all were relieved by 
operation ; but Lequyer's only slightly. 

Baylor : Trans. Eoyal Acad, of Med. in Ireland, 1903, p. 225. 

2 Heath: Med. Chir. Soc., vol. 63. 3 Boulby : Path. Soc., London, vol. 42, p. 79. 

* Twyman : Lancet, 1890, vol. i. p. 1352. 5 Meinhold : Munch. Med. Woch., 1904, No. 17. 

6 Fisk : Annals of Surgery, 1904, p. 1011. 7 Prog. Med., 1882, No. 16. 

8 Desault, Velpeau, Earle, Gibson, quoted by Gurlt, loc. cit., ii. pp. 601, 604, 606; Polail- 
lon, loc. cit., p. 696 : Mercier, Des Complications des Fractures de la Clavicule, 1881 ; 
Delens, Arch, de Med., Aug., 1881, p. 170; Stimson, N. Y. Med. Journ.', June 11. 1887; 
Poirier, La Semaine Med., Sept. 2, 1891 ; Mauclaire. Ibid., Oct. 17, 1894 ; Hassler, Lyon 
Med., January 12, 1896 ; Sieur, Bull, de la Soc. de Chir., vol. 25, p. 503 ; Davis, Annals of 
Surg., Feb., 1895; McCosh, Annals of Surg., 1902, vol. 35, p. 110; Lequver, Gaz. med. de 
Nantes, 1906, No. 15, abst. in Ztlblatt fur Chir., 1906, p. 1016. 



FRACTURES OF THE CLAVICLE. 205 

Iujmy to the lung, as evidenced by emphysema, has been recorded 
in five cases where this symptom seemed to be demonstrative, and in 
two others in which it is much more likely that the emphysema was 
due to the introduction of air through a wound of the soft parts. 

The first five cases are those of Vigarous, Velpeau, Huguier, 
Ruble, and Mercier. All except the fourth are described with all the 
details obtainable in a thesis by Mercier. 1 (See First Edition.) 

The anatomical demonstration of the immediate agency is lacking 
in all these cases, but the notes in all but one show that the surgeons 
were mindful of the possibility that a fracture of a rib might coexist 
and might have been the cause of the wound in the lung, and that 
they were unable to detect such a complication. In most of them, 
too, mention is made of the depression of the outer fragment, and as 
the relations of the clavicle to the upper portion of the thoracic cavity 
are such that it is not difficult to admit the possibility of a wound of 
the apex of the lung by the broken bone, I think the clinical evidence 
may be accepted as sufficient. 

Etiology. 

The clavicle may be broken by muscular action, by direct violence, 
or by indirect violence. 

Gurlt 2 and Delens 3 collected and analyzed a number of reported 
cases of fracture by muscular action. The efforts by which the frac- 
tures were caused were various : lifting a heavy weight ; striking with 
the hand, a whip, or racket ; making a vigorous effort that involved 
the contraction of many muscles, as in Legros Clark's case of a lad 
who, while swinging by the feet from a trapeze, tried to raise himself 
so as to seize the bar with his hands : the clavicle broke in its inner 
third during the effort. It is probable that the clavicular fibres of 
the deltoid and pectoralis major are the most efficient agents in pro- 
ducing this fracture, since their contraction tends to draw the unsup- 
ported central portion of the clavicle downward and outward toward 
the humerus when the arm is fixed. 

Closely allied to these cases are those in which the fracture has been 
produced by a blow or other force acting at the hand ; thus, an old 
woman broke her clavicle by closing the door of a wardrobe forcibly, 
and a lunatic at Bicetre broke his by striking violently with a heavy 
stick against some iron bars. 

In a very few of the cases the fracture has been produced by two 
efforts, or a blow and an effort, separated by a longer or shorter inter- 
val ; the patient feels pain at some point in the clavicle after a fall or 
a blow or an effort, which persists, perhaps, but is not severe and does 
not interfere with the use of the arm ; and then in a few days, after 
another violence or effort, the bone breaks. If the second violence 
were sufficient in itself to account for the fracture, the first one might 
be regarded as a mere coincidence, but it has generally been less than 
the first, 

1 Mercier: Des Complications des Fractures de la Clavicule, These de Paris, issi. 

2 Gurlt: Loc. cit 3 Deleus : Loc. cit., and Arch. Gen., 1875, vol. i. p. 257. 



206 FRACTURES. 

Direct fractures are produced by varied causes, and may occur at 
any part of the bone, but most frequently in the middle and outer 
thirds. The commonest form of violence is a blow falling upon the 
centre of the bone in a direction that is backward and downward. 

Indirect fractures, which constitute the great majority, are most 
frequently produced by a fall upon the shoulder or upon the hand or 
elbow, the arm being extended and the muscles rigid. In a few cases 
the fracture has been caused apparently by the sudden depression of the 
shoulder, by which the clavicle was bent over the first rib. Malgaigne l 
reports one : an incomplete fracture at the middle of the bone due to the 
slipping of a burden from the shoulder to the arm ; and Polaillon 2 
another : a man who held the end of a lever which was to receive part 
of the Aveight of a heavy stone, the stone slipped suddenly upon the 
lever and drew the arm which held it downward. The man heard a 
snap and felt pain in the shoulder ; the clavicle was broken in its 
middle third. 

The clavicle has been broken in a number of cases during intra- 
uterine life by external violence, and occasionally by the midwife or 
obstetrician during parturition. 

Symptoms and Course. 

The rational and physical signs common to most fractures are found 
in those of the clavicle. These are the deformity, mobility, and crepitus, 
the localized pain, and the diminution of function. Besides the 
deformity due to the displacement of the fragments, there is also that 
which is produced by the falling inward of the shoulder and which is 
most apparent when viewed from behind, and with it goes a very 
noticeable projection of the posterior border and inferior angle of the 
scapula. 

In fractures of the middle third there is usually displacement of such 
a character and extent that there is no difficulty in recognizing it and 
its cause; the fragments can be separately grasped and moved upon 
each other. Crepitus, however, is not always produced by this manoeu- 
vre, for the broken surfaces may not be in contact, and in order to get 
this symptom it may be necessary to have the shoulder drawn back- 
ward and outward, so as to reduce the displacement. 

Localized pain on direct pressure or when the shoulder is pressed 
inward is a valuable sign in partial fractures and in fractures without 
displacement, and it may be the only one that is present immediately 
after the injury ; the appearance within a week of a firm oval mass at 
the point where pain was felt confirms the diagnosis of fracture. 

The interference with function seems to be largely the consequence 
of the pain which makes the patient unwilling to move the arm, rather 
than of any mechanical defect produced by the fracture. The patient 
can usually move the arm quite freely backward and forward, but 
cannot raise it or adduct it without pain, and if asked to put his hand 

1 Malgaigue : Loc. cit., p. 463. 2 p laillou : Loc. cit., p. 679. 



FRACTURES OF THE CLAVICLE. 207 

on his head, will usually flex the forearm, incline the body, and bend 
down his head to accomplish it. The fracture and displacement are 
not entirely without influence in this limitation of the movements, but 
they are not wholly responsible for it. Hurel, 1 who profited by his 
internat at the hospital for convalescents at Paris, to examine the later 
condition of patients with this fracture, found the movement of cir- 
cumduction of the arm the last to be regained, and that a shortening 
of half an inch or more delayed complete recovery considerably beyond 
the time that was sufficient for it when the shortening was less or 
absent. 

The patient's appearance is often quite characteristic ; he sits with 
his body and head inclined toward the injured side and supports the 
elbow with the other hand. The only cases in which the diagnosis can 
well remain in doubt after even a brief examination are those of incom- 
plete fracture, and some of fracture close to either end of the bone 
which may be mistaken for dislocation. On the other hand, the crep- 
itus which is so frequently present in dislocation of the acromial end 
of the clavicle, because of the chipping of the edge of the joint, may 
lead to a diagnosis of fracture. Either error may be avoided if the 
outline of the bone can be accurately traced. 

The progress of the fracture is simple and is rarely disturbed by 
complications or dangers. Union is usually firm by the end of the 
fourth week, sometimes much earlier, and failure of union is rare. 
Displacement and shortening, however, are the rule ; only those cases, 
apparently, are exempt in which the line of fracture is transverse 
and there is no displacement at first. The amount of the shortening 
may vary from a fraction of an inch to one and even two inches, and 
it may be produced by angular displacement, or by overriding, or by 
both. 

The complications that may occur in the course of the repair are the 
ordinary inflammatory ones that may arise at the seat of fracture in 
consequence of the bruising of the surrounding parts, or of the failure 
to immobilize the fragments, or special ones due to the pressure of the 
fragments or callus upon the vessels and nerves. (See above, Com- 
plications.) Delens's 2 case is very satisfactory. The patient was 
brought to the hospital January 1, 1881, with fracture of the left 
clavicle and two ribs. The arm was placed in a Mayor's sling, and 
union was complete by the end of the month. The patient returned 
on March 19th, complaining of great loss of power in the left arm ; 
examination showed marked overriding of the fragments, the outer 
lying in front of the inner one, with a hard, firm callus two inches 
thick, atrophy of all the muscles of the left arm, and passive conges- 
tion of the skin of the hand ; the pulsations of the left radial artery 
were much weaker than those of the right. The posterior and lower 
portion of the callus was removed by operation, the pulsations of the 
radial artery and the appearance of the hand at once became normal, 

1 Hurel: Les Fractures tie la Clavicule, These do Paris, L867. 

2 Delens : IV la resection d'un calde la Clavicule compriniant les vaisseauz et les aerfs 

sousclaviers, in Archives do Medeeine, August, L881, p. 170. 



208 FRACTURES. 

and the patient gradually recovered the use of the limb. McCosh 1 
briefly reports a case relieved by dissecting the plexus out of a mass 
of cicatricial tissue apparently caused by fracture. 

In another case Gosselin removed a portion of callus which had 
caused persistent ulceration of the soft parts covering it. A prompt 
cure followed. 

Ossification of the coraco-clavicular ligament has been observed in 
several cases after fracture in the outer third. No description is given 
of the modifications, if any, of the functions of the part produced by 
this anchylosis. 

Failure of union is rare, and in the few .cases which have been 
recorded it does not appear to have resulted in any diminution of func- 
tion ; in one case carefully examined by Hamilton where there was 
ligamentous union and overriding to the extent of half an inch the arm 
on the affected side was in every way as strong and as fit for use as the 
other. 

Simultaneous fracture of both clavicles is a relatively rare accident. 
Writing in 1881, I found twenty-eight cases collected by five authors, 
but a year seldom passes now without the report of one or more cases. 
In position, symptoms, and mode of production these double fractures 
do not differ materially from single ones. Sometimes they are pro- 
duced simultaneously by lateral pressure upon the shoulders, some- 
times successively by two different blows, and once simultaneously by 
a kick by a horse, each hoof breaking a clavicle. 

In three of the six cases collected by Malgaigne, union failed in 
both bones, and he has left a very complete account of the resultant 
disability in one of them which was under his own care. In the 
others there was apparently but little permanent interference with the 
functions of the arms. In none of the recently reported cases has 
failure of union been noted. In recent cases there is sometimes con- 
siderable dyspnoea, which Hurel thinks is due to the weight of the 
arms and shoulders upon the thorax, aided perhaps by the loss of 
power of the accessory muscles of respiration, those which pass from 
the neck or thorax to the clavicle and scapula. This dyspnoea is relieved 
by the dorsal decubitus if the shoulders rest upon a firm support. 
The condition of Malgaigne's patient on examination three years after 
the accident was as follows : the shoulders appeared to be below, in 
front of, and on the inner side of their normal positions, the shoulder- 
blades stood out posteriorly three or four inches from the chest-wall 
and were inclined forward and outward, and the upper part of the 
chest seemed much contracted. The clavicles were broken at the 
centre, and the outer fragments were below and behind the inner ones. 
The shoulders could be drawn back slightly, but not enough to over- 
come the displacement forward, and they could be drawn forward so 
far that they were separated by an interval of only three inches, meas- 
uring across the chest. The arms could be raised to the horizontal 
line in front and on the side, but not behind. 

1 McCosh : Annals of Surgery, 1902, vol. xxxv. p. 110. 



FRACTURES OF THE CLAVICLE. 209 

Treatment. 

The indications for treatment are to reduce the displacement and 
to prevent its recurrence. The means by which they are to be met 
do not differ materially in the different fractures, but in describing 
them I shall have mainly in mind fractures of the middle third. 

As has been already said, the FlG 85 

shoulder and outer fragment are A 

usually displaced inward, forward, , /^^ / 

and downward, and the outer end ^T^^^^. 

of the inner fragment is displaced 1 //^ ^***^ W 

upward. The force which pro- yl ^^"*" ""^^^>^ 

duces the first displacement is the "11/ ^x^ 

weight of the shoulder. It must If \ 

be remembered that the shoulder /4 f^*^_ 

hangs out from the chest as a sign \f L V ' <2mS^ 

hangs out from the side of a house ; ^^pr 

the Scapula and clavicle are two Mechanism of displacement after fracture of 

lateral Supports, and the trapezius ^clavicle: a, acromion ;c, clavicle ;s,scap- 

, . * L r . ula ; a', position of the acromion after the 

muscle is a suspensory one. A f rac ture. 
glance at Fig. 85 shows how the 

fracture of the clavicle removes one lateral support, and how the 
weight of the shoulder, being no longer supported upon that side, 
swings forward and inward until a new equilibrium is found. This 
movement of rotation carries the posterior portion of the scapula 
away from the back at the same time that it brings the anterior portion 
nearer the front, and as the upper part of the chest is dome-like and 
not simply cylindrical, and as the movement, the change of position, 
takes place therefore in a vertical as well as in a horizontal plane, the 
shoulder drops and the inferior angle of the scapula rises, by compari- 
son at least, if not actually. Reduction, therefore, is to be accomplished 
by carrying the shoulder back to its former position, and retention by 
supplying the support previously given by the clavicle. These indi- 
cations have been clearly understood since the time of the earliest 
writers, but it has been found very difficult to embody them in practice, 
because there is no means of acting in the desired manner upon the 
shoulder that does not involve an amount of discomfort that patients 
will not ordinarily submit to. Moreover, in some cases surgeons have 
lost sight of the fact that the position of the arm is a secondary one, 
its importance being due solely to its use as a means of acting upon 
the outer end of the scapula, and that it is useless to press the elbow 
upward unless the scapula is left free to be raised by that pressure. Tt 
is entirely useless to bind the elbow to the shoulder on the same side ; 
such dressings do not raise the scapula. 

One of the methods of reduction employed by Hippocrates resembles 
in principle very closely the dressing suggested by Velpeau and em- 
ployed with much success by him and others. He placed the hand of 
the affected side upon the opposite shoulder and then pressed the elbow 
forcibly upward and outward. As the arm lies thus across the chest 
ils long axis is exactly in the direction in which pressure should be 
14 



210 FRACTURES. 

made to overcome the usual displacement. Another method employed 
by Hippocrates was to place the patient upon his back with a small, 
hard cushion between his shoulders, and then to press backward upon 
the acromion or the head of the humerus while the elbow was pushed 
up by an assistant. Paul us iEgineta made extension by drawing the 
arm upward and outward, and counter-extension by the neck or other 
arm (recently revived by Bardenheuer), and he also recommended the 
axillary pad with the elbow brought close to the side. Guy de Chauliac 
placed his knee between the patient's shoulders and drew them back- 
ward. These methods are the types of all that have since been used or 
that are now in use. 

Reduction, in short, is to be sought by carrying the shoulder upward, 
outward, and backward, acting either directly upon it or indirectly 
through the elbow, or using the arm as a lever. Polaillon recommends 
strongly a method based upon the latter principle; standing behind the 
patient he passes the hand or forearm into the axilla, and draws upward 
and backward with it, while with the other hand he presses the elbow 
against the side and thus forces the shoulder outward. 

In some cases it is necessary to have these efforts made by an assist- 
ant in order that the surgeon himself may be at liberty to make such 
movements of coaptation as may be needed to overcome the obstacles 
offered by points or irregularities upon the surface when the line of 
fracture is transverse or nearly so. In transverse fractures with only 
angular displacement upward and forward it is sometimes sufficient to 
make pressure upon the angle. 

The physical obstacles that need to be overcome in the treatment are 
so great and the success that has attended the different methods has 
often been so moderate that the number of plans that have been pro- 
posed and employed is very great, and the history of the treatment 
shows mainly a recurrence of periods marked at first by elaboration 
and multiplication of details and precautions and then by the abandon- 
ment of them all and the substitution of something very simple. The 
results obtained by the simple scarf or sling are often as good as those 
furnished by the most elaborate bandaging, and the discomfort to the 
patient during treatment is much less. 

The differences in the methods depend in great part upon the indi- 
cation which each surgeon has had more particularly in mind, upon the 
displacement which he sought to prevent. Thus, in some, the special 
object of the dressing is to maintain the shoulder elevated, in others to 
hold it back, and in others again to draw it outward. The type of the 
first class is a band passing under the elbow and forearm and around the 
neck, the forearm lying across the chest. That of the second is a pos- 
terior transverse splint to the ends of which the shoulders are made 
fast, or an anterior transverse splint pressing the shoulder back. That 
of the third is the axillary pad used as a fulcrum to force the shoulder 
out by pressing the elbow in. 

When the patient is sufficiently desirous to avoid any visible irreg- 
ularity in the outline of the clavicle to bear the discomforts of a 
prolonged rest in bed without change of position, and when the dis- 
placement can be reduced, treatment in the recumbent position holds 



FRACTURES OF THE CLAVICLE. 



211 



out the best prospect of recovery without deformity. The patient should 
be placed upon his back (or rather upon her back, for it is not probable 
that any one but a lady whose social position requires her neck to be 
left at times uncovered will submit to this confinement), upon a firm 
mattress with the neck bent so as to relax the sterno-cleido-mastoid upon 
the injured side, and the elbow fastened to the side or chest or raised 
upon a cushion so that the weight of the arm may tend somewhat to 
force the shoulder upward and backward, anatomically speaking. It 
has been recommended also that a firm narrow cushion be placed along 
the spine between the shoulder-blades, and Robert preferred to have the 
patient lie not entirely flat upon the back, but inclined slightly toward 
the uninjured side. In one case digital pressure was made upon the 
fragments throughout the treatment to insure accurate coaptation. 
The position must be kept practically unchanged for at least two, and 
probably for three, weeks. 

Goutrand l has modified this by keeping the arm dependent beside 
the bed for a week or two, and claims excellent results. The position 
is less irksome if the forearm is kept flexed by attaching the wrist 
either to the arm or to the side of the bed. 

Mayor's scarf or sling (Fig. 86) is made of a square of muslin, 
the diagonal of which is long enough to extend easily around the body. 




Fig. 87. 




Fracture of the clavicle, 
scarf. 



Mayor's 



Velpeau's dressing for fracture 
of the clavicle. 



The forearm is flexed at a right angle and laid across the breast : the 
cloth^ folded diagonally, is laid over it and tied around the body so 
that its folded border runs horizontally around an inch or two above 
the forearm, in front of which the cloth hangs down. The free point 
of the triangle is then brought up between the forearm and the body, 
and the two folds of which it is composed are secured, one on either 
side of the neck, by bands attached to the scarf behind and brought 
1 Goutrand: Bull, et Mem. de la Soc. do Chir., 1907, vol. 83, p. tUt. 



212 



FRACTURES. 



forward over the shoulder ; or the forearm is placed between the folds 
of the triangle, the folded diagonal of which thus forms the lowest part 
of the dressing, while its ends are tied around the body as before. The 
folds that form the third point are tied together about the neck. 

This method is suitable for fractures without much displacement, 
especially for those in children with untorn periosteum. 

Velpeau's dressing (Figs. 87) is more secure. It is made with a 
long roller-bandage. The elbow is brought well in front of the chest 
and the hand placed on the opposite shoulder, and the limb is drawn 
snugly up toward the neck by successive turns of the roller which, 
beginning at the opposite axilla, pass obliquely across the back, over 
the shoulder, in front of the arm, under the elbow, and back to the 
axilla ; after three or four such turns have been placed the bandage is 
carried circularly around the body covering in the arm from below 
upward. The turns should be secured by stitching or by soaking in 
dextrine or plaster. 

Sayre's Dressing (Figs. 88 and 89). A very convenient and 
popular dressing is the one introduced by Prof. Sayre. It is made of 



Fig. 88. 



Fig. 





Sayre's adhesive plaster dressing for fracture 
of the clavicle. First piece. 



The same. Second piece. 



two strips of stout adhesive plaster, each about three inches wide and 
long enough to go once and a half around the body ; one end of the first 
strap is stitched closely about the arm just below the axilla, and the 
other carried around the chest from behind forward, as shown in Fig. 
88. The second strap is then carried from the top of the shoulder on 
the uninjured side across the back, under the elbow, and along the fore- 
arm to the shoulder again (Fig. 89). The elbow should be drawn back 
while the first strap is applied, and well forward while the second is. 



FRACTURES OF THE CLAVICLE. 213 

The object of the first strap is to fix the upper middle portion of the 
arm, so that when the elbow is brought forward by the second one the 
shoulder should be forced backward and upward. It is a convenience to 
the patient to have the plaster carried past the ulnar side of the hand 
so as to leave the latter uncovered. The action of the dressing is 
simply to press the shoulder upward and backward, and its principal 
advantage lies in the solidity which the use of the adhesive plaster 
gives. A thin pad of absorbent cotton may be placed in the axilla to 
absorb perspiration. 

The axillary pad, designed especially to prevent shortening by 
forcing the shoulder outward, has been in use for many centuries, and 
reached its highest development at the hands of Desault, of whose 
complicated dressing it forms the essential part. I believe that when- 
ever it is large and firm enough to accomplish its object it is dangerous, 
and whenever small enough to be free from danger it is useless. 

The dressings which are intended mainly to draw the shoulder back- 
ward are modifications of the figure-of-eight bandage and the posterior 
and anterior splints. The simple figure-of-eight carried across the back 
from one shoulder to the other, either in muslin or plaster of Paris, I 
have found to interfere too much with the circulation in the arms if effi- 
ciently applied. In two cases of marked displacement which could be 
reduced by drawing the shoulders back, but which recurred under the 
usual dressings, I obtained a satisfactory result by the use of a breast- 
plate made of crinoline soaked in plaster cream and covering the front 
of the chest and shoulders. The shoulders were held back and reduc- 
tion maintained until the plaster had set, and then the position was 
maintained by a figure-of-eight bandage. The heavy ends of the 
breast-plate in front of the shoulder prevented compression of the 
axillary vessels by the bandage, and the dressing was Avorn with com- 
fort for three or four weeks. 

Mayer and Cordua * recommend that the forearm should be fixed 
behind the back and the shoulder held back by a strip of adhesive 
plaster passing across its front to the back. Mayer had used it only in 
a case of fracture of the outer third, but Cordua appears to have gen- 
eralized its use. He says that patients soon adapt themselves to it. 

A modification of the figure-of-eight suggested by Recamier amounts 
almost to a posterior splint. He placed a large, hard square cushion 
between the shoulders behind and carried a bandage from each upper 
corner over the shoulder and under the axilla back to the lower corner. 

Posterior splints have been made in the form of a cross, against 
the arms of which the shoulders were drawn back, and as iron, wooden, 
and pasteboard splints crossing the back and extending usually beyond 
the shoulders, so that the traction of the bandages by which the shoul- 
ders were made fast should be exerted in an outward direction as well 
as backward. 

A fixed support shaped like the upper end of a crutch and fastened 
to the side of the chest by adhesive plaster has been occasionally sug- 
gested and even used. Like the axillary pad it is probably intolerable 
or dangerous if applied efficiently. 

1 Mayer and Cordua: Zentralblatt fur Chir., 1906, pp. 1004 and 1200. 



214 FRACTURES. 

It is apparent that while many different dressings may give good 
results in certain cases, none can be depended upon to do so in all, and 
that the displacement, the shortening, which is the rule in the adult, is 
the result in some cases of forces which cannot be effectually controlled, 
of the obliquity of the fracture, and not infrequently of the indocility 
of the patient, who, finding himself incommoded by the dressing, shifts 
it slightly, but often, until he obtains ease at the sacrifice of the object 
it was applied to secure. 

If the fracture is without displacement, especially the subperiosteal 
fracture of children, or if the displacement shows but little tendency 
to recur after reduction, the simple scarf or sling or Sayre's dressing 
will answer every purpose. 

If, on the other hand, the tendency to displacement is great, the 
choice of a method of treatment will depend largely upon the character 
and wishes of the patient. If he is indifferent to the deformity or 
intolerant of restraint, it is useless to attempt more than a simple 
dressing ; but if he is willing to submit to the confinement, the fracture 
may be treated by dorsal decubitus and digital pressure with a fair 
prospect of success, or by the plaster-of-Paris breast-plate and figure- 
of-eight bandage. Fortunately, persistence of displacement does not 
necessarily cause loss of function. 

In simultaneous fracture of the two clavicles, the dorsal position is 
strongly to be recommended. 

It is well to place in the axilla a pad of cotton wrapped in a com- 
press to absorb the moisture and keep the opposing surfaces from con- 
tact with each other ; and for the same reason a compress should be 
placed between the arm and the body, wherever the two would other- 
wise be in contact. 

The dressing should be worn for from fifteen to twenty days by 
children, and twenty to thirty days by adults. 



CHAPTEE XVIII. 



Fig. 90. 



FRACTURES OF THE SCAPULA. 

Feactures of the scapula clinically recognized are comparatively 
rare, about 1 per cent, of all fractures according to the best statistics at 
our command, but Lane's * observa- 
tions in the dissecting-room indicate 
that fractures of the acromion are 
very common and must, therefore, 
usually pass unrecognized. They 
are six times as common in men as 
in women, and in the great majority 
of cases the patients have been be- 
tween twenty and fifty years of age. 

The size and shape of the bone, 
and the presence of three irregular 
and prominent apophyses permit a 
diversity of fractures differing so 
greatly in their mode of production 
and symptoms that it becomes 
necessary to consider them sepa- 
rately. Most writers in the last 
hundred years have made from six to 
eight groups as follows: 1st, frac- 
tures of the body ; 2d, fractures of 
the inferior angle ; 3d, fractures of 
the upper angle and supra-spinous 
fossa ; 4th, fractures of the spine ; 
5th, fractures of the acromion ; 6th, 
fractures of the coracoid process ; Fracture across body of the scapula, with 

(7,i n. , ,i i xi «i separation of a long piece of the spine. A. 

7th, fractures through the surgical 

neck; 8th, fractures of the glenoid cavity. Of these varieties the 1st, 

4th, and 5th are by far the most common ; the others are extremely 

rare. 

1. Fractures of the Body of the Scapula. 

Fractures of the body of the scapula are single or multiple. The 
former are confined to the subspinous fossa, and the direction of the 
line of fracture is transverse or oblique. The fragments may preserve 
their normal relations to each other or there may be displacement, the 
lower fragment shifting to either side of the upper one ami overriding 
for a greater or less distance. This overriding is most marked on the 
axillary side and is due apparently to contraction of the teres major 

1 Lane : Ciuy's Hospital Reports, 1886, vol. xliii. p. -US. 

•J 13 




216 



FRACTURES. 



is 

may 

some 



and serratus, while the lateral displacement is the result of the continued 
action of the fracturing force. In some cases the fragments have 
united after transverse or oblique fracture in such a position that they 

touch or override at one side and 
Fig. 91. are separated at the other. 

In multiple fractures the lesion 
extremely variable, the fracture 
be " starred," or comminuted, 
of the lines may be incom- 
plete, and the main one may be longi- 
tudinal ; the only condition, appar- 
ently, under which longitudinal 
fracture is met with (Fig. 91). 

The fracture may be partial, in 
the form of a fissure running from 
one border, or circumscribed, a cen- 
tral piece being broken out. 

The cause of the fracture has 
almost always been direct violence, 
usually a blow or a fall upon some 
angular object, but in three reported 
cases it appears to have been caused 
by muscular action, as in similar 
fractures of the inferior angle (q. v.), 
the line of fracture being somewhat 
The cases are those of Dobson, 1 Leidy, 2 




Multiple (longitudinal) fracture 
scapula. 



the latter. 



the 



higher than in 
and Hoover. 3 

The objective symptoms which may be met with are irregularity in 
outline, abnormal mobility, crepitus, and ecchymosis. The posterior 
border and inferior angle of the bone can be made prominent by carry- 
ing the elbow forward and inward, and then if the finger is passed 
along it a transverse or oblique fracture with displacement will be cer- 
tainly recognized. Abnormal mobility and crepitus can be recognized 
by grasping the inferior angle and moving it while the upper portion 
is steadied by the other hand. In multiple or partial fractures with 
depression the adjoining edge of bone may be felt if the patient is not 
too fat or muscular. The precaution should always be taken to make 
a comparison with the other scapula, and the normal ridges along the 
borders and at the base of the spine should be borne in mind. Ecchy- 
mosis, unless due to the action of the violence upon the soft parts, 
seldom appears until after the lapse of a few days. 

Localized pain on pressure and on movement of the arm is a con- 
stant symptom, and may make it impossible for the patient to ex- 
tend his arm horizontally and directly forward because it is so much in- 
creased by the contraction of the muscles concerned in this movement. 

The course in the simpler cases ends in recovery in four or five weeks, 
usually with preservation of function even if union has taken place 



1 Dobson : Lancet, November 27, 1886. 

2 Leidy : University Medical Magazine, March, 1891. 

3 Hoover : Medical and Surgical Eeporter, 1893, p. 848. 



FRACTURES OF THE SCAPULA. 217 

with some unreduced displacement. Multiple fractures are more dan- 
gerous because of the greater probability of suppuration at or in the 
neighborhood of the fracture, and of course if the fracture is a com- 
pound one the danger is still greater. In a very few instances there 
has been much disability due to failure of union or to union with dis- 
placement and exuberant callus. Gurlt quotes an example of the 
former in which the patient was unable to raise his hand to the back 
of his neck, and one of the latter in which the disability was almost 
complete and all communicated movements of the arm and shoulder 
were painful. 

Treatment. In simple fracture without displacement no other treat- 
ment is needed than immobilization of the arm and shoulder during 
the length of time necessary for consolidation. If displacement exist 
it must be corrected, if possible, by placing the arm and shoulder in 
various positions and pressing upon the fragments with the hands 
in the directions indicated by the displacement. When the latter is 
reduced as far as possible the arm and shoulder must be immobilized 
by binding the arm to the side or merely supporting it in a sling, and 
a broad strip of adhesive plaster may be laid across the scapula to aid 
its immobilization. 

In comminuted fractures the principal indication is to prevent the 
severe inflammatory reaction which is so likely to follow the bruising 
and laceration produced at the same time by the extreme violence that 
has caused the fracture. If the fracture is compound it must be 
explored through the wound and treated in accordance with the prin- 
ciples elsewhere laid down, and it is prudent in such cases to remove 
partly adherent fragments which could be safely left after fracture of 
other bones, whenever by such removal a free outlet that would other- 
wise be lacking is supplied to matter that may accumulate on the under 
(costal) surface of the bone. In a few cases of simple fracture pus has 
formed and caused much trouble by burrowing down the side of the 
body, confirming the experience furnished by some simple fractures of 
other bones, in which pus has formed apparently in consequence of 
imperfect immobilization. 

2. Fractures of the Inferior Angle. 

These are included by some writers in the group of fractures of the 
body of the scapula, from which they differ merely by the proximity 
of the line of fracture to the lowest part of the bone, but as they pre- 
sent a more constant and well-defined displacement which cannot be 
readily overcome or prevented they deserve separate mention. The 
recorded instances of separate fracture are not very numerous. Gen- 
soul reported one produced by muscular action ; the patient saved him- 
self from falling to the ground while descending a sharp incline, either 
by catching hold of some support or by falling backward upon his 
outstretched hand ; the abstracts of the report are not clear upon 
this point. A triangular piece corresponding to the inferior angle was 
detached from the scapula and displaced forward and upward, and could 
be moved independently and with crepitus. Gensoul attributed the 



218 FRACTURES. 

fracture to the sharp contraction of the teres major. Guinard 1 reports 
a second case and quotes a third, 2 the only one he could find. He 
adds a detailed study of fractures of the body and inferior angle by 
muscular action and quotes the reports of all the known cases. The 
histories of these cases and of those of fracture of the body suggest the 
possibility, even the probability, that muscular contraction was the 
cause in many others in which the history of a fall upon the back led 
to the easy assumption of fracture by direct violence. 

Symptoms. The symptoms are clear and unmistakable : displace- 
ment of the fragment forward and upward by the combined action of 
the serratus magnus and teres major ; abnormal mobility recognized by 
grasping the fragment with one hand and moving it, or by fixing it 
with one hand and moving the scapula with the other ; and crepitus. 
In one case 3 the displacement was said to have been downward. 

The displacement is difficult to maintain reduced, because the small- 
ness of the fragment prevents efficient control of it, and the tonicity of 
the muscles tends constantly to draw it away ; but while this ensures 
some deformity it is slight and does not add seriousness to the prognosis. 

3. Fractures of the Upper Angle. 

These are very rare. Gurlt gives a figure of a specimen preserved 
in Dresden, and Hamilton of one in Philadelphia. In the latter a 
fissure extends well into the subspinous fossa. In both repair has 
taken place without much displacement. Gurlt records two cases 
observed during life ; in each the injury was the result of a fall upon 
the back ; in one there was no displacement, in the other the fragment 
was drawn upward and inward by the levator anguli scapulae. Texier 4 
reports a case ; the cause was direct violence ; prompt recovery. 

Treatment. The treatment is to immobilize the arm and shoulder in 
the position that is most comfortable, securing the scapula with a body 
bandage or strips of adhesive plaster, and the arm by binding it to the 
body with the forearm flexed across the chest. 

4. Fractures of the Spine of the Scapula. 

There are no known specimens of isolated fracture of the spine of 
the scapula, and our only knowledge of them is clinical. In those 
I have seen the diagnosis was readily made by recognition of the 
abnormal mobility, with crepitus, of the fragment, and sometimes of an 
irregularity in the outline of the spine. 

Treatment. The treatment is as before ; immobilization of the arm 
in a suitable position, and local antiphlogistic remedies if required. 

5. Fracture of the Acromion. 

The alleged frequency of this fracture has been called in question by 
those who deem most of the museum specimens examples either of 

1 Guinard: Archives generates de Med., April, 1896. 

2 Sabatier : Union Medicale, 1857, p. 397. 

3 Denuce : Journ. de Med. de Bordeaux, 1892, vol. i. p. 571. 

4 Texier : Journ. de Med. de Bordeaux, April 5, 1896. 



FRACTURES OF THE SCAPULA. 219 

a traumatic separation of the epiphysis or of n on -ossification. The 
former would still belong under the head of fractures, and, even if we 
exclude the others, there are still clinical instances in sufficient number 
to make the lesion one of the most common. 

The acromion is exposed to fracture by blows received directly upon 
it, and also through the humerus, as in a fall upon the elbow, and occa- 
sionally by muscular action. The line of fracture is usually perpen- 
dicular to the axis of the apophysis, but is sometimes oblique. It lies 
most frequently either in front of the acromioclavicular joint or at 
the root of the acromion, rarely at an intermediate point. 

The symptoms are those of fracture, and of the contusion if the 
agency has been direct violence ; and as the latter are prominent and 
may obscure the former, the fracture may be overlooked. The signs 
common to both are ecchymosis, local or extending down the arm, 
swelling, and pain. The additional signs of fracture are increase of 
the local pain on pressure and on moving the arm, usually complete 
inability to abduct the arm, abnormal mobility, and crepitus, and pos- 
sibly displacement. 

The displacement varies with the position and extent of the fracture. 
If the latter involves only the outer end of the apophysis, the displace- 
ment is slight and downward by the contraction of the attached fibres 
of the deltoid, the shoulder loses a little of its roundness in consequence, 
but the head of the humerus retains its place. If the fracture is near 
the base of the apophysis, the weight of the arm tends to draw the 
fragment downward and inward, turning it upon the outer end of the 
clavicle as a centre, and the shoulder is flattened. The finger passed 
along the spine recognizes an irregularity in the outline, usually a 
depression of the outer fragment, but sometimes an elevation or a 
transverse groove or gap in which the end of the finger can rest. 

Crepitus can often be got by lifting the elbow directly upward, so 
as to push up the acromion, or by abducting the arm ; and abnormal 
mobility must be sought by varied manipulations of the apophysis and 
by moving the arm. 

The commonest functional disturbance is the inability to raise the 
arm, although this is not a constant symptom, while the power of rota- 
tion is preserved unaltered, even if somewhat painful. 

Bony union appears to be the exception, the fragments uniting by a 
fibrous bond of greater or less length and solidity ; the rupture or the 
preservation of the periosteum must be of almost controlling impor- 
tance in determining the character of the union. Apparently, bony 
union takes place only when the fragments remain in close contact. 
In one case the distal fragment became necrosed and was cast out. 

Treatment. The treatment consists in reduction of the displacement 
by pressing the head of the humerus upward against the acromion, 
and in securing it in this position by a bandage passing about the 
body and the arm. The dressing should be worn lor about throe 
weeks. 



220 



FRACTURES. 



6. Fracture of the Coracoid Process. 

This may be caused by muscular action or by direct or indirect vio- 
lence ; in the former the causative effort is sometimes comparatively 
slight — wringing wet clothes in one case — but more often is a powerful 
effort made with the arm. In fractures by direct violence other bones 
— ribs, arm, clavicle — are usually coincident!)' broken ; those by indi- 
rect violence appear, according to the observations of Lane/ to be most 
commonly produced by pressure of the tip of the process against the 
clavicle in forced flexion of the shoulder ; other instances are those in 
which the fracture is produced by the impact of the dislocated head 
of the humerus. 

The line of fracture is usually about an inch behind the apex of the 
process, but sometimes is further back, passing close to the upper edge 
of the glenoid cavity in a line that corresponds so nearly to the position 
of the epiphyseal cartilage that some observers consider some specimens 
to be examples of separation of the epiphysis, or even simply of delay 
in ossification. Normally this conjugal cartilage ossifies at about the 
fourteenth year. Bennett 2 pub- 
lished a case of separation of the Fig. 93. 
epiphysis, verified by autopsy, in a 
child six years old. In one of Mal- 

Fig. 92. 





Fracture of the coracoid process. 



Fracture at base of coracoid. 



gaigne's and in two of Gurlt's cases the end of the process was also 
split longitudinally into two pieces, one remaining attached to the ten- 
don of the biceps, the other to that of the pectoralis minor. 

A unique case of fracture across the base of the coracoid and the 
upper part of the glenoid fossa is reported by Braun 3 and represented 
in Fig. 93. The patient had been struck by a locomotive. 

The displacement is seldom great, because the fragment is prevented 
from yielding to the action of the attached muscles by the coraco-cla- 
vicular ligament ; still, in one of the last-mentioned cases the fragments 
were displaced more than half an inch downward. Petty 4 gives a ski- 
agram of a case of fracture by muscular action showing fracture at the 
middle with tilting downward and inward of the distal portion. 

1 Lane : British Medical Journal, May 19, 1888. 

2 Bennett: Dublin Journ. Med. Sciences, August, 1888. 

3 Braun : Arch, fur klin. Chir., vol. 42, p. 110. 

4 Petty : Annals of Surg., March, 1907. 



FRACTURES OF THE SCAPULA. 221 

Symptoms. The symptoms are abnormal mobility and crepitus, but 
are not easily recognized, especially if the soft parts be much bruised 
and swollen ; the depth at which the process is placed, and the thick- 
ness of the overlying muscles, make it difficult to grasp the process 
between the lingers or to appreciate its independent mobility. I have 
also noticed localized pain on forcible voluntary adduction of the arm 
and flexion of the forearm. 

The fracture in itself involves no danger to life, and no probable 
disability, although the union is seldom bony. Of six specimens exam- 
ined by Gurlt bony union was found in only one ; in four cases men- 
tioned by him of which our knowledge is only clinical, mobility 
persisted in two. This failure of union does not seem to cause any 
loss of function. In Hulme's case the union was firm but the frag- 
ment somewhat displaced downward. 

Treatment. The treatment must be directed to immobilizing the 
arm in a position which will relax, as well as may be, the muscles 
attached to the process. Theoretically, the best position is that in 
which the forearm is flexed and the elbow carried across the front of 
the chest, but this cannot be carried out thoroughly without causing 
more discomfort than the benefit to be obtained by it will warrant ; 
and it is best, therefore, simply to fix the arm against the side with 
the forearm comfortably flexed. 

7. Fractures of the Neck of the Scapula. 

Under this term, following Gurlt, I include not only fractures 
which pass from the suprascapular notch to the axillary border of the 
scapula in a direction parallel to the surface of the glenoid cavity, 
but also those which begin in front of the base of the coracoid process 
(sometimes even within the articular border) and pass obliquely down- 
ward and backward to the axillary border. There is no known exam- 
ple of fracture running close behind and parallel to the glenoid fossa 
along what is sometimes termed the anatomical neck. 

The small anterior fragment always carries with it the attachment 
of the triceps and usually the entire coracoid process ; but the liga- 
ments which bind the coracoid process to the clavicle and acromion 
remain untorn, as does also a ligament extending from the under sur- 
face of the spine of the scapula to the edge of the glenoid cavity, and 
they limit the displacement. 

The cases in which this fracture has been verified by dissection are 
six in number : the cases of Duverney, Neill, and Spence, a specimen 
in the museum of Guy's Hospital and another in that of the Royal 
College of Surgeons at London, and one found by Lane. 1 Gurlt de- 
scribes the first three, and Flower 2 mentions the next two. The exact 
character of Neill's 3 case is uncertain ; in Spence V* (Fig. 94) the frac- 
ture passed in front of the coracoid process ; in the others it appears to 
have passed through the suprascapular notch. 

1 Lane: Loc. cit., p. 415. 

2 Flower: Holmes's System of Surgery, Am. od.. vol. i. p. 851. 

:t Neill : American JoUTll. Mod. Sciences, new scr.. 1858, vol. xxxvi. p. 105. 

4 Spence: Edinburgh Medical Journal, June, 1863, p. 1082. 



222 FRACTURES. 

Cause. The cause has been a fall or blow upon the shoulder; May 1 
reported a case caused in a girl by the effort of placing a handkerchief 
about her neck, but it seems more probable from the description that 
the injury was a fracture of the coracoid. 

Farabeuf found that if the anterior portion of the capsule was 
made tense by outward rotation of the arm the neck could be broken 

Fig. 94. 



Fracture of the neck of the scapula. Spence's case. (Guklt.) 

by a blow on the back of the head of the humerus or by one upon 
the elbow if the arm was also directed backward. 

Symptoms. The symptoms of the fracture are the flattening of the 
shoulder, the prominence of the acromion, the absence of the head of 
the humerus from the axilla (where it would be found if the injury 
were a dislocation), the easy reduction of the displacement by raising 
the elbow, its immediate return when the support is Avithdrawn from 
the elbow, and the crepitus which accompanies these movements. In 
two of Gurlt's cases the fragment could be felt in the axilla. The 
power of voluntary motion of the arm is lost, but passive movements 
are free, and, within certain limits, painless. On the other hand, 
manipulations which reduce the displacement or bring out crepitus 
cause much pain. Sometimes the lower edge of the fragment can be 
felt in the posterior and outer part of the axilla as a hard movable 
body which can be pushed upward, with pain and crepitus, but falls 
back as soon as the pressure is removed. In a case reported by Ash- 
hurst, 2 crepitus was obtained by grasping the parts between the fingers 
on the shoulder and the thumb deep in the axilla and rotating the 
arm. There was very slight displacement. In a personal case a point 
of pain on pressure could be found by passing the finger high up along 
the axillary border of the scapula. 

The most characteristic symptom is the easy reduction and the imme- 
diate return of the displacement, and it is this which distinguishes it 
most sharply from dislocation of the humerus, the prominent symp- 
toms of which are so similar. 

Prognosis. According to Gurlt, bony union is the rule, fibrous union 
the exception, but in both cases with slight displacement of the frag- 

1 May : London Medical Gazette, 1842-43, p. 49. 

2 Ashhurst: Trans. Coll. of Physicians, Phila., 1875, 3d ser., vol. i. p. 69. 



FRACTURES OF THE SCAPULA. 



223 



meiit forward and downward. His collection contains only two cases 
of fibrous union ; in one the patient had fair use of the arm, in the 
other the limb was entirely useless. In the cases where bony union 
was secured, repair was complete in from four to seven weeks; in 
some there was slight diminution of the usefulness of the limb, but in 
the majority its use was fully regained. 

Treatment. It is doubtful if the parts can be supported by any 
dressing so perfectly that union without any displacement can be 
secured. The indications of treatment are to oppose the constant dis- 
placement downward and forward or inward by supporting the elbow ; 
probably the dressing which I have found so efficient in dislocation of 
the acromial end of the clavicle (q. v.) would answer the purpose if the 
ends of the plaster strip were carried further inward on the shoulder. 



Fig. 95. 



8. Fracture of the Glenoid Cavity. 

In almost all the instances that are on record this fracture has been 
discovered post mortem or during operation after dislocation of the 
shoulder. It is thought to be not uncommon, but as the diagnosis is 
very difficult its frequency cannot be determined. Usually the frac- 
ture is of the inner border of the articular surface, but sometimes the 
outer or lower border has been broken off ; and Flower says that frac- 
tures have been found running across the glenoid fossa and even split- 
ting it into several portions. Poland l showed a 
specimen of stellate fracture of the fossa with three 
lines radiating thence to the body ; there was also 
fracture of the acromion, but no dislocation. Agnew 
gives a similar figure, but does not state the source 
from which it was derived. 

Symptoms. The symptoms cannot be described 
because no case appears to have been recognized 
during life ; and it seems unlikely that a diagnosis 
could be made with any positiveness. The frag- 
ment is small and not accessible to direct manipu- 
lation, so that the only symptoms would be those 
of a dislocation together with crepitus on reduction, 
and perhaps a ready recurrence of the dislocation 
— signs that may be present under a variety of circumstances. 

Treatment. Treatment must be limited to reduction and immobili- 
zation, and the latter should be more complete and better guarded than 
after a simple dislocation, because of the greater ease with which the 
head of the humerus can escape from the glenoid cavity when the rim 
of the latter is broken. 




1 ii_ 



Fracture of eda:e of arle- 
noid fossa. (V. Bruns.) 



Poland : British Medical Journal, January 23, 1S92. 



CHAPTER XIX. 

FRACTURES OF THE HUMERUS. 

The tables in Chapter I. show that, while fractures of the upper 
extremity ( including the clavicle ) constitute nearly half of all 
fractures, those of the humerus are only 4 per cent, of all, and this 
bone is less frequently broken than either the clavicle, radius, or 
ulna. Different tables of statistics show great variations in the rela- 
tive frequency of the fractures of the different portions of the bone, 
some giving the greatest number to the shaft, others to the lower end, 
but all agree in giving the greatest frequency to the first twenty years 
of life. 

The different varieties of fracture may be most conveniently studied 
by arranging them in three groups : fractures of the upper end, frac- 
tures of the shaft, and fractures of the lower end, although the first 
and third groups severally contain varieties which differ materially 
from one another. 

For a remarkable case of longitudinal fracture extending the entire 
length of the bone which cannot be placed in any one of these groups, 
the reader is referred to page 27. 

1. FRACTURES OF THE UPPER END OF THE HUMERUS. 

The fractures of this region include fissures and chippings of the 
articular head, fractures of the tuberosities, of the anatomical neck, and 
along the epiphyseal line, and a group comprising the great majority 
of fractures in this region in which the line of fracture crosses the bone 
in a variety of ways between the anatomical neck and the lower bor- 
der of the surgical neck, which is commonly drawn at the insertions 
of the teres major and pectoralis, and which includes fractures pro- 
duced by compression, so-called, cross-strain, and torsion. Above, 
this group unites with or closely approaches fractures of the anatomical 
neck, and below with oblique and comminuted fractures of the adjoin- 
ing portions of the shaft. Its upper limit may be placed at those frac- 
tures which pass along or very close to the lower (inner and posterior) 
portion of the anatomical neck and then reach the outer side through 
the greater tuberosity ; the lower limit may, for clinical reasons, be 
conveniently placed low enough to include even quite oblique fractures 
in which one end of the line rises to the surgical neck. Between those 
at the upper limit and fractures of the anatomical neck are some in 
which the line is doubled on the outer side — a fracture of the anatomical 
neck with a second line passing through the tuberosities from about the 
middle of the first. As these, like pure fractures of the anatomical 
224 



FRACTURES OF THE HUMERUS 225 

neck, are frequently associated with anterior dislocation of the shoulder, 
and as they lack the clinical characteristics of the lower fractures, I 
shall describe them in the same section with fractures of the anatomical 
neck, but under a separate title — -fractures through the tuberosities ; their 
lower line is the same as that of the highest of the main group (frac- 
tures of the surgical neck), the distinction lying in the addition of a 
line along the anatomical neck detaching the head. The lower main 
group is characterized clinically by the fact that the upper fragment is 
peculiarly subject to the unopposed action of the scapular muscles ; a 
separate class is made of separation of the epiphysis in the young, but 
fractures in the adult which follow in the main the former line of the 
conjugal cartilage are not separated from the main group. 

In this section, then, will be considered fractures of the head, of the 
anatomical neck, through the tuberosities, of the tuberosities, and of 
the surgical neck, and separation of the epiphysis. 

A. Fractures of the Head. 

Simple fissures or partial fractures of the head of the humerus with- 
out associated fracture of the tuberosities or surgical neck are very rare. 
To the two instances which Gurlt quotes from Gosselin and Gross l 
may be added, I think, three others, one described by Malgaigne, 2 the 
other two by Houel. 

Houel's first case is a specimen in the Musee Dupuytren ; about one- 
third of the head of the humerus has been broken off and has reunited. 

His second case, also in the same museum, is a specimen of fracture 
through the head separating a thin fragment entirely covered with 
articular cartilage. The fragment was turned completely over and not 
united. The patient was an old woman and died seven or eight months 
after the receipt of the injury. 

The cases are much more numerous in which the articular surface is 
fractured in connection with fracture of adjoining parts ; and in ante- 
rior dislocation of the shoulder (q. v.) deep indentation or bruising of 
the surface of the head by the edge of the glenoid fossa is apparently 
not infrequent. 

B. Fracture of the Anatomical Neck, and Fracture Through the 

Tuberosities. 3 

Fracture of the anatomical neck, without an additional line of frac- 
ture through the tuberosities, is apparently a very rare, and also a very 
obscure, injury, except in association with anterior dislocation of the 
shoulder. Although it is described, and the means of diagnosis given, 
in all systematic works upon the subject, it must be admitted, 1 think, 
that our knowledge of it is extremely scanty and uncertain, being 
limited to a few specimens and to a few cases clinically observed in 
which the diagnosis remains more or less doubtful. The reported 
specimens of fresh fracture, without dislocation or additional fracture 

1 (h-oss' Surgery, fifth ed., vol. i. p. 5>s.v - Malgaigno's Atlas. Plate iv. Fig. 2. 

8 It is to be noted that some "writers include both forms under the title " Fracture of the 
Anatomical Neck." 
15 



226 



FRACTURES. 



through the tuberosities, are those of Boyer 1 and Spence ; 2 both patients 
were aged, and in each the injury was caused by a fall upon the shoul- 
der. The reported specimens from cases in which the fracture was 
associated with dislocation are more numerous, but in so many of such 
cases associated fracture of the tuberosities, generally without displace- 
ment, is mentioned that it seems probable it may have been overlooked 
or passed without comment in many of the others. These specimens 
have been obtained in the course of operations undertaken for the 
removal of the dislocated head or for the reduction of the dislocation. 
Usually the head remains attached to the shaft by a strip of perios- 
teum or capsule, and in three of my own cases the line of fracture 
diverged from the neck and split off a thin piece of the shaft adjoining 
the lowest portion of the head. 

The clinical cases are obscure, even uncertain. A number of sup- 
posed cases have recently been rej>orted in which the diagnosis rested 
upon skiagraphic showings, but the skiagrams, as published, leave 
in my mind much doubt of the accuracy of this diagnosis ; it seems 
probable that the line in fracture runs in part, at least, through 
the tuberosities. Kocher 3 reports three cases in which he thought 
this diagnosis could be made. The first was a man seventy-nine 
years old who fell from a height upon his side ; the shoulder was 
swollen ; no deviation of the axis of the arm ; shortening half a centi- 
metre ; active motion lost, passive motion gave distinct crepitus. The 
head projected in front below the acromion and could be drawn 
downward away from it, so that the finger could be passed in beneath 

the acromion and could there feel be- 
hind the fulness of the head in the 
region of the anatomical neck the 
edge of the lower fragment directed 
backward In the second case, also a 
fall upon the side, the patient was 
nineteen years old, and the edge 
could be similarly felt ; movements 
were very painful. The third patient 
was a woman sixty-one years old ; the 
cause a fall upon the front of the 
shoulder. Slight swelling, pain, loss 
of function, crepitus on rotation of 
the arm ; displacement of the upper 
fragment upward could be felt. Figs. 
96 and 97 represent his conception 
of the fracture and the displacements. 
. I have seen only one case in which the diagnosis seemed probable. 
The patient, whom I presented to the New York Surgical Society, 4 
was a man about thirty-five years old, who had fallen on his back "in 
front of a horse-car in such a way that, as the car passed over him, the 



Fig. 96. 



Fig. 97. 





Supposed displacement and line of frac- 
ture of anatomical neck of the humerus. 
(Kocher.) 



1 Boyer: Traite des Maladies Chirurgicales, 1831, vol. iii. p. 199. 

2 Spence: Edinburgh Medical Journal, 1860, vol. v. p. 1140. 

3 Kocher : Praktisch wichtiger Frakturformen, 1896. 

* Stimson : New York Medical Journal, March 19, 1891, p. 310. 



FRACTURES OF THE HUMERUS. 



227 



edge of the front platform caught against his right elbow and pressed 
the humerus with great force against the scapula. Swelling and pain 
at the shoulder, complete loss of function ; the tuberosities rotated with 
the shaft ; the acromion, coracoid, and neck of the scapula were unin- 
jured; pressing the arm upward against the acromion gave pain and 
was accompanied by crepitus. He was treated in the recumbent posi- 
tion with moderate continuous traction for five weeks, and made a 
complete recovery. 

On another occasion I had an opportunity to examine an undoubted 
case. The patient had suffered the fracture with dislocation, and I 
was able clearly to recognize the small, movable upper fragment in the 
axilla. Under anaesthesia I was, fortunately, able to reduce the dis- 
location, and then, being in presence of a fracture of the anatomical 
neck without dislocation, I examined it carefully in order to ascertain, 
if possible, a means of diagnosis ; but I could detect nothing abnormal, 
no deformity, no crepitus ; after the anaesthesia had ended, pressure 
upward at the elbow or backward at the front of the shoulder caused 
pain. 

This shows that the fracture can exist without other symptom than 
pain on pressing the fragments together, and that crepitus on moderate 
movements of the limb may be absent ; which, indeed, is not surprising 
when it is remembered how easily the head can move in its socket and, 
consequently, how likely it is to share in the movement of the lower 
fragment if it is at all closely connected with it by irregularities of the 
line of fracture. Probably the most that can 
be said in any case is that there is a fracture 
above the surgical neck, but whether it is purely 
of the anatomical neck or combined with frac- 
ture through the tuberosities or even partly of 
the neck and partly through the tuberosities is 
likely to remain uncertain, because the deter- 
mining fact — the relations of the upper part of 
the greater tuberosity with the shaft, its move- 
ment with it or its independence of it — may 
easily be beyond exact determination. 

Of fracture through the tuberosities the ex- 
amples are much more numerous. To a frac- 
ture of the anatomical neck may be added one 
or more lines of fracture passing from the first 



Fig. 98. 



through the tuberosities, 



or 



the 



ine may 



pass 




Fracture of the anatomical 
neck of the humerus, with 
slight splintering and frac- 
ture of both tuberosities. 
(GtTRLT.) 



along the lower (posterior and internal) portion 
of the neck and then diverge through the tuber- 
osities. The fresh specimens have almost all 
been obtained from cases of combined fracture 
and dislocation, and our periodical literature 
now contains almost every year one or more instances. I have had 
two such, fracture of the anatomical neck with fissuring of the greater 
tuberosity, in which I removed the head, and have seen two others 
under the care of colleagues. 

The distinction between this variety and the higher form of fractures 



228 



FRACTURES. 



of the surgical neck (as I have here defined the latter) is arbitrarily 
drawn and I doubt, for the reasons given, if it can often be recognized 
clinically. Because of its mode of production — violence acting directly 
against the upper end of the bone from the outer side or in front — it 
is, I think, much more frequently associated with dislocation of the 
upper fragment than are fractures at a somewhat lower level which 
seem more commonly to be caused by cross-strain. Independent mo- 
bility of only the upper part of the tuberosity would at least show that 
the fracture was high. 

Two specimens described and pictured by R. W. Smith 1 (Figs. 99 
and 100) show healing with marked impaction in one case and with 
complete reversal of the head in the other. In the one shown in Fig. 
100, examined five years after the accident, "the head of the humerus 
was found to have been drawn into the cancellated tissue of the shaft 
between the tuberosities so deeply as to be below the summit of the 



Fig. 99. 



Fig. 100. 





Fracture through the tuberosities of the 
humerus. Reversal of the head. (R. W. 
Smith.) 

greater tubercle ; this process had 
been split off and displaced out- 
ward ; it formed an obtuse angle 
with the outer surface of the shaft 
of the bone." 

The specimen illustrated in Fig. 
1 00 is described by the same author 
as " impacted fracture of the neck 
of the humerus, accompanied by 
fracture of both tubercles. " " The head of the bone was found to have 
been separated from the shaft by a fracture which traversed the ana- 
tomical neck of the humerus. It was reversed in the articulation, so 
that the fractured surface was directed upward toward the glenoid 
cavity, and the cartilaginous articulating surface thrown downward 

1 E. W. Smith : Fractures iu the Vicinity of Joints, 1S54, p. 192. 



Impaction of the head of the humerus into 
the shaft, with splitting off of the tuberosi- 
ties. (R. W. Smith.) 



FRACTURES OF THE HUMERUS. 229 

toward the shaft, and having assumed this position it was driven to a 
considerable distance into the cancellated structure between the tuber- 
cles. From this violent impaction of the head of the bone into the 
lower fragment a second fracture resulted which split off the lesser 
tubercle along with about two-thirds of the greater, and a small por- 
tion of the shaft of the humerus, corresponding to the upper part of 
the bicipital groove." 

The outer part of the cartilaginous surface of the head was buried 
to a depth of nearly an inch, but the inner part was free ; the cartilage 
remained perfect, and was not united to the cancellated tissue of the 
tubercles; the rest of the fragment was firmly united with the tissue 
of the tubercles, and their union also was complete. A similar case is 
reported by Kronlein l and one bv Korte. 2 (See also Gurlt, vol. ii. p. 
693.) 

Doubtless, also, the upper fragment may undergo that displacement 
inward and downward by the rising of the shaft under the action of 
the deltoid which was pointed out by Jonathan Hutchinson as occurring 
in those cases which I here classify as high fractures of the surgical 
neck, and which at a later period may easily be mistaken for unre- 
duced dislocation. 

Repair is largely carried on by the distal portion of the bone, and is 
marked by an exuberant production of callus and osteophytic growths 
on the surface and sometimes by ossification of the adjoining portion 
of the capsule. 

Of the fate of the small upper fragment after fracture of the anatom- 
ical neck we have little positive knowledge. Boyer's statement that 
in his case the fragment had been diminished by absorption has been 
extensively quoted, but as the patient died only seven days after the 
injury was received the accuracy of the observation is doubtful. 
Kocher does not state the result in his cases, but in McBurney's in 
which the fragment was restored to its place by operation, and in mine 
in which a presumably similar fragment was restored to its place by 
manipulation, and in my other in which the fragment was not dislo- 
cated and the diagnosis is not certain, recovery with good function fol- 
lowed. Probably the head in most cases retains some vital connection 
through untorn portions of the capsule, and experience at other joints 
shows that similar fragments can reunite or can remain as unirritating 
loose bodies in the joint. 

Treatment. Treatment is clearly limited to immobilization of the 
joint, possibly aided by some traction to oppose the tendency of the 
muscles to draw the shaft upward and thus displace the head. 



C. Fractures of the Tuberosities. 

Isolated fracture of either tuberosity is so rare an accident, except 
in connection with dislocation of the shoulder, that very tew cases are 
on record, and none that have been verified by direct examination while 

1 Kronlein: Deutsche Zeitschrift 1". Chirurgie, 1874, p. 1. 
a Korte: Langenbeck's Archives, 1882, vol. xxvii. p. 749. 



230 FRACTURES. 

fresh. Partial fracture of the greater tuberosity, that is, the fracture 
of a larger or smaller portion comprising some or all of the facets to 
which the supraspinous, infraspinatus, and teres minor muscles are 
attached, is a not infrequent accompaniment of anterior dislocation of 
the humerus, 1 and has also been seen by Malgaigne 2 in a case of dislo- 
cation backward under the acromion. (See Anterior Dislocations of 
the Shoulder.) Fracture of the lesser tuberosity is much more rare. 

A number of cases have been reported of fracture of the greater 
tuberosity with symptoms so closely resembling those of dislocation 
that the diagnosis of the latter lesion was at first made in each case, 
and a study of the reports makes it seem probable that this diagnosis 
was correct, the dislocation having then been unwittingly reduced 
during the manipulations ; most of the specimens found at autopsies 
probably belong in the same class. 

Gurlt quotes a case of supposed fracture of the tuberosity by mus- 
cular action, in which the symptoms were extreme passive mobility at 
the shoulder, complete loss of voluntary outward rotation, and partial 
loss of voluntary elevation of the arm. If the arm was rotated vigor- 
ously and the ear laid upon the patient's shoulder, crepitus could be 
heard. Four weeks later the corresponding muscles were still power- 
less and atrophied. The patient was a muscular youth of twenty years, 
and the lesion was produced by an effort to throw a snow-ball with 
force ; something was heard to crack and the arm fell powerless. The 
only mention of displacement in the case is that the patient's brother, 
a physician, thought the arm was dislocated and "made a sort of 
reduction." 

In 1881 I saw at the Presbyterian Hospital a youth of nineteen 
years who had been injured the preceding day. He said that while 
holding the bridle of a horse in his right hand the animal reared, and 
as he came down his breast struck against the patient's left forearm 
which was held before his face in protection, and threw him to the 
ground. The left shoulder was somewhat swollen ; there was an 
ecchymosis at the lower border of the tendon of the pectoralis major ; 
voluntary abduction possible ; voluntary external rotation impossible ; 
firm pressure upward at the elbow painless. The lesser tuberosity 
moved with the shaft on rotation ; crepitus observed high up in the 
shoulder when the head of the bone was grasped between the thumb 
and fingers and they were moved ; pain on pressure upon the greater 
tuberosity. I inserted an insect-pin in front at the bicipital groove 
and passed it backward its full length, evidently between two bony 
surfaces, and by pressing its point against the inner one and rotating 
the arm the continuity of this surface with the shaft was shown. My 
diagnosis was fracture of the greater tuberosity by muscular action, 
by outward rotation of the arm in the effort to ward off the descending 
body of the horse. 

I have seen a few cases of pain at the greater tuberosity on pressure 
and on voluntary outward rotation, but without crepitus or abnormal 

1 For a review of a number of cases, see Wohlgemuth, Deutsche Gesellschaft fur Chir., 
1900, ii. p. 375. 

2 Malgaigne : Atlas, Plate xxii. Figs. 5 and 6. 



FRACTURES OF THE HUMERUS 



231 



Fig. 101. 



mobility, which I have regarded as minor effects of similiar muscular 
action, the partial rupture or detachment of the tendon or possibly the 
avulsion of a small piece of the bone ; in one of them the ic-ray showed 
fracture of the upper portion of the tuberosity. 

Graessner 1 and Jacob, 2 with the aid of the arrays, have found it 
frequently after falls upon the shoulder, and think it a frequent cause 
of the stiffness which follows such blows. Graessner saw 23 examples 
in three years ; 20 were due to direct violence, 3 to a full upon the out- 
stretched hand. So many errors of interpretation of a'-ray plates are 
made that some doubt must remain as to the accuracy of these statements. 

The line of fracture usually runs along the sulcus making the 
anatomical neck at the part where it adjoins the tuberosity and down 
the bicipital groove, sometimes liberating the long tendon of the biceps 
from its sheath and allowing it to slip in between the fractured sur- 
faces. If the separation is complete the fragment is drawn upward 
and backward ; if incomplete, that is, if the periosteum remains untorn 
on the side of the fragment adjoining the shaft, new bone fills up the 
lower part of the gap, and the upper part of the fragment stands out 
from the surface from which it has been 
torn, as in Fig. 101. When union takes 
place it is almost always bony. 

I believe that in all cases in which the 
fracture is not an incident of a dislocation 
the cause is the direct action of the at- 
tached muscles. Some writers ascribe it 
almost without exception to direct external 
violence, but I know of no cases to support 
the opinion except the .T-ray findiugs quoted 
above. The diagnosis must be made by local- 
ized pain on pressure and on attempted volun- 
tary outward rotation of the arm, and by the 
abnormal mobility of the fragment, possibly 
with crepitus. 

Treatment. The treatment is immobiliza- 
tion with as much outward rotation of the 
arm as is practicable in order to diminish 
the pull of the attached muscles. Any ten- 
dency to inward displacement, such as was 
noted by Smith, should be opposed by a pad 
in or below the axilla. Keen in 1907 (personal communication) 
exposed the fragment and sutured it as nearly in place as he could 
bring it; and Niehaus 3 says he has done it several times. Wohlgemuth 
says Schuler in two cases relieved the limitation of abduction caused 
by contact of the fragment with the acromion by chiselling away a 
portion of the tuberosity. 

Fractures of the lesser tuberosity are extremely rare. Guilt collected 




Fracture of the greater tuberosity 
of the humerus united. 



1 Graessner : Veroff. aus dem Gabiete Militar-Sanitats., lift. 35, p. ISO. 

2 Jacob : Gaz. des Hop., 1903, pp. 109, 123. 
"'Niehaus: Arch, klin Chir., 1904, vol. 73, p. 71. 



232 FRACTURES. 

only three cases, two of them accompanying dislocation of the shoul- 
der, the third a specimen in the museum at Giessen. In each of the 
first two a small hard lump could be felt on the inner side of the head 
of the humerus, not moving with it. A very few other cases, certainly 
or probably associated with dislocation, have been reported, among 
them two by Bardenheuer. 1 The only case not so associated and 
which seems beyond question is that of Lorenz, 2 whose paper may be 
profitably consulted for an analysis of reported cases. His patient was 
a man forty-five years old, whose arm was forced into outward rota- 
tion, with an audible crack. He was treated for a contusion. When 
seen, three months later, by Lorenz active inward rotation was almost 
lost, outward rotation increased 40°, and a bony irregularity tender in 
pressure could be felt at the site of the lesser tuberosity. A slightly 
movable piece of bone could be indistinctly felt below the coracoid. 
The outlines of the shoulder were normal. 

Jossel 3 reports two cases accompanying backward dislocation of the 
shoulder (q. v.) ; in both the tuberosity remained attached to the sub- 
scapularis, and in one it was broken into two pieces. Engel 4 reports 
one. 

Treatment. The treatment would be immobilization in inward rota- 
tion, possibly aided by pressure on the outer aspect of the shoulder to 
oppose a tendency to outward displacement. 

D. Separation of the Epiphysis. 

The upper epiphysis of the humerus comprises the head and the 
tuberosities. The epiphyseal line runs upward and outward along the 
lower and inner half of the anatomical neck and then transversely 
under or through the tuberosities to the outer edge, its level rising as 
the individual grows older, and passing above part of the insertion of 
the teres minor. Its centre is higher than its edge, so that the shaft 
terminates in a low cone or wedge, with a corresponding hollow on 
the under surface of the epiphysis. This cone is very low in early 
life and its height increases as the individual grows older, until ossi- 
fication of the conjugal cartilage takes place, usually by the twentieth 
year, but sometimes as late as the twenty-fifth. 

This lesion has been observed at all ages between the moment of 
birth and the age of nineteen years. Jetter, 5 in an account of sixteen 
cases operated upon by Bruns, mentions two cases aged twenty-three 
and twenty-four years, but no mention is made of the presence of the 
conjugal cartilage in either, and in one the line of fracture followed 
that of the epiphyseal junction for only half an inch. Both, I think, 
belong in the class of fractures after ossification of the cartilage, and 
are examples of the rather common high fractures of the surgical neck 
in Avhich the line of fracture frequently follows the former epiphyseal 

1 Bardenheuer : Deutsche Chirursie, Lief 63 a, p. 168. 

2 Lorenz : Deutsche Zeitschrift fur Cliir., 1900-01, vol. lviii. p. 593. 

3 Jossel : Deutsche Zeitschrift fur Chir., 1874, vol. iv. p. 125. 

4 Engel : Arch, fur klin. Chir., 1897, vol. 55, p. 603. 

5 Jetter: Beitrage zur klin. Chir., 1892, vol. ix.^p. 361. 



FRACTURES OF THE HUMERUS. 233 

lines quite closely. In 66 eases collected by J. Hutchinson, Jr., 1 (J 
occurred at birth, 4 during the first year, and 17 at or above the age of 
fifteen years. In a considerable number of the recorded cases it was 
produced by the efforts of the midwife or physician to hasten delivery 
by drawing upon the presenting arm, or with the finger hooked into 
the axilla, or to bring down the arm from the side of the head when 
the legs and body were already delivered. In others it has been caused 
by falls, by forcibly drawing the arm upward and outward, and by a 
fall upon the elbow when it was held behind the axillary line. See 
also a paper by Linser. 2 

Considering how easily the epiphyses can be separated by the 
cross-strain produced in forcibly carrying the limb beyond the normal 
limit of motion in the corresponding joint established by the capsule, 
ligaments, and muscles attached to it, it seems probable that this is 
the mechanism in most cases, and in this may probably be included 
forced rotation of the arm. 

The opportunities for direct examination of the seat of injury have 
been largely increased of late by operations undertaken for the correc- 
tion of the displacement, often while recent. They show that the line 
of fracture almost always follows the epiphyseal line closely and that 
the periosteum remains untorn to a considerable extent, especially pos- 
teriorly, and that where torn its separation often takes place at some 



Fig. 102. 



Fig. 103. 





Separation of the upper epiphysis of the humerus ; dis 
placement forward of the lower fragment. (Moore.) 



Upper epiphysis of the humerus at 
10 years; separated by maceration. 

Outer side. (Moore.) 



distance below the line of fract ure , N the portion between the rent and 
the line of fracture being stripped from the shaft and remaining 
attached to the epiphysis as an irregular sleeve. The younger the 
patient the more marked apparently is this sleeve formation. 

1 1. Hutchinson, Jr., British Medical Journal, July S, 1898. 
2 Linser: Beitrage zur klin. Chir., 1900-01, vol. xxix. p. 360. 



234 



FRACTURES. 



The displacement is habitually of the shaft forward, and some- 
times to the outer or to the inner side, the posterior portion of the end 
Fig. 104. Fig. 105. 




.Separation of upper epiphysis of humerus 



Fig. 106. 




Separation of the epiphysis, with an oblique fragment from shaft. Outward displacement ot 

shaft, (v. Bruns.) 

of the shaft usually lodging in the saucer-shaped lower surface of the 
epiphysis, the latter being flexed and abducted (Fig. 102). Excep- 



FRACTURES OF THE HUMERUS. 



235 



tionally the displacement inward of the upper end of the shaft may 
be such as completely to separate the fractured surfaces and lodge the 
end of the shaft beneath the coracoid process. There is reason to 
think that in some cases there is no displacement. The upper frag- 
ment may be rotated outward. 

Symptoms. The symptoms are so characteristic that it is difficult to 
understand why the mistake of supposing the injury to be a disloca- 
tion should have been made so frequently. The anterior edge of the 
upper end of the shaft can be distinctly felt at the front of the shoulder 
an inch or more below the acromion, and often so raises the skin that 
its presence can be seen as well as felt. The arm usually hangs 
straight with the elbow directed a little backward, or it may be 
abducted, but the suggestion of a dislocation which the latter attitude 
gives is at once removed by palpation of the shoulder which shows the 
head of the humerus to be in its place, and if the head is grasped 
between the thumb and fingers and the arm gently rotated the inde- 
pendent mobility of the two will be recognized, perhaps with crepitus. 
The anterior displacement of the upper end of the shaft is well shown 
in Fig. 103. 



Fig. 107. 



Fig. 108. 




Union after separation of the upper 
epiphysis of the humerus with displace- 
ment. (R. w. Smith.) 




Separation of upper epiphysis of humerus. Excision 
of projecting end of shaft. (Kocher.) 

In cases without displacement the di- 
agnosis could be made only bv the local- 



ized 



pain on pressure, on pressing 



the 



on attempting to 



cial importance here because 
humerus in length takes place at its upper end. 
When the displacement persists various results 



elbow upward, and 
use the limb. 

If displacement is absent or has been 
corrected repair takes place habitually 
without incident, although occasionally 
the trauma has led to premature ossifica- 
tion of the conjugal cartilage and conse- 
quent arrest of growth, a matter ot' spe- 
the greater part of the growth o\' the 



are 



ible 



23(3 FRACTURES. 

may take place (Fig. 107), and the subsequent range of motion be 
restricted by the deformity ; as the epiphysis is already flexed and 
abducted motion of the arm in those directions is restricted, and 
motion in other directions may be interfered with either by the faulty 
position in some respects (e. g., inward rotation) of the lower fragment 
or by the contact of projecting portions with adjoining apophyses. Or 
suppuration may follow ; in the reported cases it is not entirely clear 
that the suppuration was not provoked by injudicious attempts to 
reduce a supposed dislocation, or that it may not have been a sponta- 
neous osteomyelitis preceding the separation of the epiphysis, the latter 
being the result, not the cause, of the suppuration. Or, very rarely, 
reunion may fail. 

In respect of treatment the first effort must be to correct the dis- 
placement ; this can sometimes be effected by traction upon the arm 
aided by direct pressure upon the projecting fragment, but in other 
cases it is advisable to use the plan suggested by Dr. E. M. Moore, that 
of forcibly raising the elbow beside the head so as to bring the shaft 
into a position corresponding with that taken by the epiphysis ; as the 
latter is prevented by the posterior portion of the capsule from moving 
further in this direction, the forced movement of the arm throws the 
upper end of the shaft backward into place. Interposition of the torn 
and loosened periosteal sleeve may create so serious an obstacle that 
reduction cannot be effected without the aid of an incision exposing the 
seat of fracture. In the older cases ossification of the untorn periosteum 
rapidly produces a bony bridge between the fragments which pre- 
vents reduction. In two such cases Kocher cut away the projecting 
portion of the shaft (Fig. 108) and increased the range thereby; others 
have resected the callus and a portion of the diaphysis and then made 
reduction. 

After reduction immobilization of the limb for three or four weeks 
is necessary. It is only in cases in which reduction is incomplete that 
measures are required to oppose a tendency to recurrence of the dis- 
placement. 

E. Fracture of the Surgical Neck. 

Under this rubric are here included fractures of the portion of the 
bone lying between the site of the epiphyseal cartilage and the insertion 
of the pectoralis and teres major, the great majority of all fractures of 
the upper end of the bone. The line of fracture in separation of the 
epiphysis in the young marks the upper limit of this group in adults ; 
its lower limit is an arbitrary and ill-defined one and, moreover, is not 
infrequently crossed by fractures which lie partly above and partly 
below it. The higher fractures of the group are separately described 
by some as fracture through the tuberosities, fractura pertubereularis, 
but the distinction does not seem worth preserving. 

The common cause is external violence, a fall or a blow upon the 
arm, but occasionally is muscular action. The mode of action is rarely 
clear in the history of a given case, but experiment has thrown light 
upon it. The higher fractures may be caused by a blow or fall upon 
the upper part of the arm or upon the elbow, presumably aided by the 



w 

Oh 




3 

«-. 


o 
Z 

o 







FRACTURES OF THE HUMERUS. 



2:37 



resistance of the glenoid fossa or the acromion, the so-called u com- 
pression " fractures, but much more frequently, I think, by a cross- 
strain in which the upper end is fixed by the resistance of the capsule 
and ligaments and possibly the muscles, and either the elbow is forced 
outward or forward or is fixed in abduction while the blow is received 
on the outer part of the shoulder, " abduction fractures;" " adduction 
fractures," by violence acting in the opposite direction, are much rarer, 
The lower fractures may be caused by violence acting on the side of 
the shaft at or below the point of fracture, or by cross-strain in a fall 
on the elbow or hand, or by torsion of the limb. 



Fig. 109. 



Fig. 110. 




Upper and lower limits of fracture 
of the surgical neck of the humerus ) 
with spiral fracture of shaft extend- 
ing into the area. 




Impacted fracture of the surgical neck of the humerus. 
(R. W. Smith.) 



In the higher and some of the lower fractures the line is essentially 
transverse, usually with splintering or even comminution, sometimes with 
fissures extending through the head and sometimes with notable impac- 
tion. Many of the lower fractures are oblique, often markedly so. 

The upper fragment, since opposition to the action of the muscles 
attached to it is diminished or annulled by the fracture, often takes the 
attitude of flexion, abduction, and outward rotation, being sometimes 
aided therein by the impaction into it of the lower fragment (Plate VI.) ; 
the latter is usually displaced inward, partly by the momentary con- 
tinuation of the fracturing force in some cases and partly by the action 
of the pectoralis and teres major. Exceptionally the displacement is 
equal to the thickness of the shaft, and may be outward or posterior, as 



238 



FRACTURES. 



shown in some of the figures; but in the great majority of cases the 
displacement is too slight to be clinically recognizable. 

An important form of impaction is that in which the shaft passes to 
the front and outer side of the head and the latter is thereby brought 
to a lower point on its inner side (Fig. 110). It is claimed by Hutch- 
inson that the rising of the shaft under the pull of the deltoid may 
press the head so far inward and downward that the final position may 
resemble that of a dislocation below the coracoid. 



Fig. 111. 





Fig. 113. 



Fig. 114. 





Figs. 111-114. Forms of fracture at the upper end of the humerus, .r-ray tracings. 



The tendon of the long head of the biceps may be torn in these 
extreme displacements. Injury of the axillary vessels and nerves is 
extremely rare ; thrombosis of the artery in consequence of bruising 
has been seen, the axillary vein has been torn in a compound fracture, 
and the musculo-spiral nerve has been so compressed as to cause paral- 
ysis of motion and sensation in its area of distribution. 



FRACTURES OF THE HUMERUS. 



239 



In an oblique fracture the sharp end of the lower fragment may 
approach or become engaged in or even perforate the skin, usually on 
the inner side, and even in the higher fractures this has been observed 
in front close below the acromion. 



Fig. 115. 



Fig. 116. 








Fig. 117. 



Fig. 118. 





Figs. 115-118. Forms of fracture at the upper eud of the humerus, .r-ray tracings. 



For the combination of fracture with dislocation see Dislocation o{ 
the Shoulder, Chapter XLTV. 

Symptoms. The symptoms vary with the form of fracture and tlie 
displacement; usually the arm hangs by the side or the elbow is slightly 



240 



FRACTURES. 



abducted, but if the displacement inward of the upper end of the shaft 
is marked the abduction of the arm resembles that of an anterior dis- 
location (Fig. 120); the distinction is easily made by recognition of 
the presence of the head in the glenoid fossa, maintaing the fulness 



Fig. 119. 



Fig. 120. 






Fracture of the surgical neck of the 
humerus. The dark spot is an ecchy- 
mosis. 



Fracture of the surgical neck ; displacement 
inward of the lower fragment, resembling dis- 
location. 



of the shoulder. Loss of function is usually complete, swelling 
marked, and ecchymoses very extensive, especially in the old, often 
spreading to the elbow and across the front of the chest. 

If the elbow is pressed upward pain is felt at the fracture, and dis- 
tinctly localized pain can often be caused by pressure with the finger 
along the line of fracture. 

Then if the upper fragment is grasped between the thumb and fingers 
in such a way that the notch between the tuberosities at the bicipital 
groove can be felt, and the elbow is gently rotated, the failure of the 
former to share in the movement will be recognized and usually crepi- 
tus will be perceived. In the cases with more marked displacement the 
relations of the fragments can be determined by palpation if the patient 
is not too fat or the region too swollen, or by noting the direction of the 
axis of the shaft. 

Diagnosis. In the great majority of cases the diagnosis is made upon 
the localized pain, especially on pressing the elbow upward, and on the 



FRACTURES OF THE HUMERUS. 241 

failure ot the tuberosities to share in slight rotatory movements com- 
municated to the elbow, for the displacement is usually too slight to be 
recognized through the swollen tissues. When marked displacement 
exists the position of the upper end of the lower fragment is indicated 
by the direction of the axis of the shaft, generally upward and inward, 
and is demonstrated by abnormal resistance to pressure and pain at the 
indicated point, usually corresponding to the groove between the pec- 
toralis and deltoid near the coracoid. Dislocation of the shoulder is 
excluded by recognition of the head in its place. The lower end of 
the upper fragment can be traced only in those oblique fractures where 
the line of fracture descends upon the shaft. 

Prognosis. When no important displacement persists and no compli- 
cations are present, the course is uneventful and the result good ; union 
takes place in from thirty to forty days, and the restoration of function 
is complete after a few more weeks. Exceptionally, function may be 
diminished by an associated arthritis, especially in the old, or by exces- 
sive formation of callus in the higher forms. Failure of union has 
been noted in only a very few cases with uncorrected displacement; 
and once or twice the displaced end of the shaft has become firmly 
adherent to the coracoid process. 

Treatment. Reduction of the displacement is made by traction upon 
the arm aided by appropriate pressure on the end of the lower frag- 
ment. In most cases, because of the usual abduction of the upper 
fragment, it is necessary to make traction with the arm widely abducted 
so as to bring the shaft into line with the attitude of the upper frag- 
ment, and after the displacement has thus been reduced the arm is 
lowered to the side and there maintained by suitable dressings unless 
this position too greatly favors recurrence of the displacement, in which 
case the abducted position must be maintained for a week or two. 
Exceptionally, another attitude may be made necessary by another 
form of displacement. 

The chief disturbing influence which the retentive dressing has to 
oppose is the action of the muscles, which tends to draw the lower frag- 
ment upward and inward and to flex, abduct, and sometimes outwardly 
rotate the upper fragment, and the great difficulties in the preparation 
of an always effective dressing are to find a fixed support for its upper 
end which will furnish the counter-extension for traction upon the 
lower segment and to oppose the tendency to displacement inward with- 
out making undue pressure upon the vessels and nerves of the axilla 
and inner aspect of the arm. The upper fragment is too small to be 
acted upon directly by any splint, and its position and movements can 
be controlled only through its interlocking with the lower fragment ; 
in default of such control the lower fragment must be brought into line 
with the upper in the position given to the latter by its attached mus- 
cles. Counter-extension against the folds of the axilla is ineffective 
both because they are yielding and because they rest upon muscles, the 
pectoralis and latissimus dorsi, which are attached to the humerus 
below the seat of fracture, so that the force is applied to the two ends 
of the lower segment and is, therefore, ineffectual to control its rela- 
16 



242 FRACTURES. 

tions to the upper one. The desired fixation can be got by a heavv 
plaster-of-Paris dressing enveloping the chest and shoulder, but this is 
too irksome to be used except in cases of extreme need. I have used 
it with advantage in some compound fractures. Fortunately the ten- 
dency to displacement can usually be controlled by simple measures 
which are sufficiently effective in practice even if not in theory, but 
when it is great continuous traction must be used, either by "weight and 
pulley with the patient in bed, or by a weight attached to the dependent 
arm when the patient is seated or standing. 

Lateral displacement inward of the upper end of the shaft can be 
effectively opposed when the patient is in bed by moderate traction 
outward applied by a band about the upper part of the arm. No fixed 
dressing or splint can alone do it, when the tendency is marked, because 
of the presence of the main vessels and nerves on the inner side of the 
arm where they might be dangerously compressed between the bone 
and the upper part of the splint. Fixed dressings consist essentially 
of a stiff piece on the outer side of the limb, resting against the shoul- 
der and elbow, to which the arm is made fast by a bandage; this meas- 
urably controls inward displacement but not shortening. If the latter 
threatens it must be opposed by traction, although that supplied by the 
weight of the limb is usually sufficient. Occasionally the fixed dress- 
ing is a simple support between the arm and the body, by which the 
limb is immobilized in abduction ; and not infrequently it is sufficient 
simply to bind the arm to the side of the body. 

Continuous traction by weight and pulley is made through a cord 
attached to the arm above the elbow by two strips of adhesive plaster 
bound to it by a roller bandage as in the similar treatment of fractures 
of the thigh (page 97). The hand and forearm should be bandaged 
to prevent swelling. The patient should be in bed, the arm somewhat 
abducted and resting on pillows or a sliding support; weight about five 
pounds. It is rarely necessary to maintain it for more than two weeks. 

Traction with the patient out of bed can be made by a weight simi- 
larly attached to the arm or hanging from a plaster-of-Paris dressing 
as described below ; the elbow is flexed at a right angle, and the fore- 
arm supported at the wrist by a sling. 

The common shoulder-cap of leather or cardboard, capping the shoul- 
der and covering the outer aspect of the arm, or even extending to the 
elbow, is wholly inefficient against inward displacement or overriding 
and serves only to give support and to protect against chance violence. 
It must be combined with an internal lateral splint to give it more 
control over the lower fragment and with traction to prevent over- 
riding. 

A similar dressing of plaster of Paris enveloping the arm and fore- 
arm and overlapping the shoulder has the same defects, although they 
are diminished by the better control of the limb and by the weight 
of the dressings which makes efficient traction when the patient is 
erect. It can safely be used when the tendency to displacement is 
slight, especially after the second week. It can be readily made as 
shown in Fig. 126 or with the usual plaster roller-bandage, applied 



FRACTURES OF THE HUMERUS. 



243 



lightly over the forearm and more thickly on the arm as high as the 
axilla, and combined with a cap over the shoulder made by carrying 
the bandage up and down over it from the outer side of the arm. 
Overriding taking place under it can be detected by noticing that 
the cap rises above the shoulder, admitting the finger, or even two, 
beneath it ; this must be met by attaching a weight to the elbow, 
and in all cases the forearm should be supported across the chest, 
only at the wrist, in order that the weight of the arm may constantly 
draw the lower fragment down when the patient is erect. A tri- 
angular cushion extending from the axilla to the elbow between the 
arm and the chest secures slight abduction if needed and may add 
to the comfort (Fig. 128). 



Fig. 121. 



Fig. 122. 



r\ 




Hennequin's plaster splint for fracture of the humerus. 

A convenient method of making a similar plaster dressing is that 
devised by Hennequin : l a dozen thicknesses of crinoline, or "three or 
four of muslin or canton-flannel, cut as shown in Fig. 121, the width 
being equal to the circumference of the arm, and the length of the 
central portion equal to the distance from the fold of the axilla to the 
elbow, are soaked in plaster cream and applied as shown in Fio<. 122, 
the limb having previously been bandaged from the wrist to the elbow 
to prevent swelling. If overriding is present or anticipated traction 
must be made while the plaster is hardening, either by the hands or by 
a weight made fast at the elbow by a bandage under the splint. Hen- 
nequin makes temporary counter-extension bv a bandage under the 
axilla, but I doubt its value or safety ; it seems liable to lead to making 

1 Hennequin : Revue de Chirurgie, L887, 



244 



FRACTURES. 




the splint too high on the inner side and thus chafing the axillary 
folds. 

For cases in which the attitude and fixation of the upper fragment 
are such that the limb must be kept abducted so as to be in line with 

it, and in which confinement to 
bed must be avoided, a' support 
braced against the body may be 
used. Middeldorpf s triangle (Fig. 
1 23) is a type of such dressing ; 
the objection to it is in the in- 
ternal rotation which it gives to 
the arm and which may not coin- 
cide w r ith the position of the upper 
fragment. A lighter pattern is 
made of a bent rod or piece of 
stout leather strapped to the arm 
and trunk. 

The choice of these different 
methods in varying cases may be 
summarized as follows : In the 
high fractures with little displace- 
ment or tendency thereto moderate 
immobilization, support, and pro- 
tection are sufficient, and these 
may often be got by binding the 
arm to the side, especially if the 
patient is fat. If the patient is robust, and especially if the fracture 
is oblique, so that shortening by the traction of the muscles is prob- 
able, a plaster-of- Paris dressing with traction by a weight at the elbow 
is required. If the upper fragment is abducted and its position can- 
not be controlled by interlocking of the broken surfaces, the abducted 
position of the arm is necessary, and the patient should be treated in 
bed with traction in that position for a fortnight, when the upper frag- 
ment will generally be found to accompany the lower one when it is 
adducted, or out of bed with a dressing like the Middeldorpf triangle. 
Cases with marked tendency to displacement inward of the upper 
end of the lower fragment should be treated in bed with traction in 
abduction aided by moderate outward traction upon the upper part of 
the lower fragment. 

Compound fractures which suppurate need a strong fixed support 
which can be maintained during the changes of dressing, such as a 
plaster-of-Paris jacket with iron braces extending across to a plaster 
case enveloping the lower two-thirds of the arm or with a strong broad 
plaster bridge uniting the two over the top and outer aspect of the 
shoulder. In compound fractures with splintering of the upper frag- 
ment and implication of the joint, usually gunshot, excision of the head 
favors repair and the subsequent usefulness of the limb. 

In all cases the patient should be directed to move his wrist and 
fingers freely ; and fixed dressings should be removed as early as pos- 



Middeldorpf s triangle for fracture of the 
humerus. 



FRACTURES OF THE HUMERUS. 



245 




sible, and the limb supported only in a sling and protected by a 
removable shoulder-cap extending to the elbow, in 
order that massage may be used to hasten the restora- Fig. 124. 

tion of function. 

For the treatment of fracture combined with dislo- 
cation see Dislocation of the Shoulder. 



2. FRACTURES OF THE SHAFT OF THE 
HUMERUS. 

The region is that included between the insertion 
of the pectoralis major and the upper portion of the 
supracondyloid ridges. 

All the varieties of fracture which may occur in long 
bones are contained among those of the shaft of the 
humerus. A remarkable and unique example of longi- 
tudinal fracture extending the entire length of the bone 
is quoted in Chapter II. (p. 27), and Gurlt gives two 
of exceptionally long fissures, beginning in the one 
case at the condyles and ending at the insertion of the 
deltoid, and extending in the other from the upper 
border of the greater tuberosity to the lower fourth 
of the shaft. Incomplete or partial fractures are ex- 
tremely rare. 

All the forms of displacement common to fractures 
of the long bones are also found here, and no one deserves mention 
as of exceptional frequency and importance. The character of the 
primary displacement depends largely upon the fracturing force ; that 
of later displacement upon the unsupported weight of the limb and 
upon muscular action. 

Double fractures of the same bone are very rare. Simultaneous frac- 
ture of both humeri has been caused by epileptic convulsions and by 
external violence. 

Among the injuries which may be associated with the fracture are 
dislocation of the shoulder, laceration of the soft parts, and contusion 
or rupture of bloodvessels or nerves. The latter deserve special atten- 
tion because of the gangrene of the limb or the paralysis which may 
result and may be attributed to negligence in the treatment. The 
brachial artery or vein may be so crushed or bruised by direct violence 
that a thrombus forms within it and arrests the circulation ; or, more 
rarely, it may be torn by the sharp edge of a displaced fragment, or 
the vessel may be stretched across the fragment in such a way as to be 
occluded by pressure. Occasionally the injury to the artery has resulted 
in the formation of an aneurism. The museulo-spiral nerve is par- 
ticularly exposed to injury because of its close relations to the bone 
throughout so large a part of its course. (See p. 7(3.) 

Causes. The causes of fracture are external violence and muscular 
action ; the latter causes fracture in the humerus more frequently than 
in any other bone, and the causative effort has not always been very 



Longitudinal frac- 
ture of the humerus. 
(Gurlt.) 



24(3 FRACTURES. 

great. The two most common efforts which have caused it are throw- 
ing a stone and that trial of strength in which two men clasp hands 
with elbows resting on a table and strive each to force the other's hand 
aside ; the latter produces a spiral fracture. 

Compound fractures have no anatomical peculiarities that require 
mention. Gurlt collected five cases of almost complete severance of 
the arm by a blow with an axe or sabre, all of which recovered with 
preservation of the limb ; in all the wound was on the outer and ante- 
rior aspect of the limb. 

Symptoms. The symptoms are the usual ones : abnormal mobility, 
crepitus, loss of function, pain, and more or less deformity. Impor- 
tant complications, such as dislocation of the shoulder or injury of the 
artery or a nerve, have their special symptoms; the principal danger is 
that they may be overlooked because the attention is concentrated on 
the fracture. Injury to the artery is indicated by absence or weakness 
of the radial pulse, either immediately or after the lapse of a few 
hours ; sometimes the symptoms have appeared gradually, the pulse 
becoming weak, and finally disappearing, the hand numb and cold, the 
surface bluish, and after death or amputation a clot, sometimes firm, 
pale, and adherent, sometimes dark and soft, has been found in the 
artery. Injury of a nerve, usually the musculo-spiral, is shown by 
paralysis and loss of sensation or hyperesthesia in the region supplied 
by it ; paralysis or loss of sensation indicates division or destruction of 
the nerve ; hyperesthesia indicates irritation, usually by pressure. 
Paralysis of motion is often overlooked at first. 

A simple fracture in an adult, running its course without complica- 
tions, will be solidly united in from four to six weeks, and in three or 
four weeks in children. The possible complications are inflammation 
and delayed union ; the former is sometimes quite marked, and the 
latter is of more frequent occurrence in the humerus than in any 
other bone. The general and local causes which lead to delay in or 
failure of union have been discussed in Chapter VIII. It has been 
thought that the special cause in the case of the humerus is defective 
immobilization of the fragments, for when the elbow is kept at a right 
angle any vertical movement of the hand or forearm is likely to cause 
horizontal movement of the lower fragment on the upper one, and 
lateral splints cannot be fitted accurately or snugly enough to prevent 
it. It has been proposed, therefore, to treat the fracture with the elbow 
in full extension, but this position is very irksome and equal immobili- 
zation can be obtained by the use of a posterior splint the upper end 
of which overlaps and is secured to the shoulder. The supposed inter- 
position of muscle which lias been so frequentlv alleged as the cause 
has existed in none of the cases upon which I have operated because 
of failure of union. 

Treatment. Reduction is made by traction upon the condyles or the 
flexed forearm. The treatment in fractures of the upper third is essen- 
tially the same as in fractures of the surgical neck ; rest in bed, with 
continuous traction and the limb supported upon cushions, may be 
required at first. For the lower fractures abduction of the limb is not 
so often needed. The plaster-of-Paris bandage is in common use, is 



FRACTURES OF THE HUMERUS. 



247 



more .secure than lateral splints, and gives good results, but it needs 
careful watching at first, both to detect displacement and to prevent 



Fig. 1H5. 



Fig. 126. 




Plaster-of-Paris splints for fracture of the shaft of the humerus. 

strangulation of the limb. It should be carried from 
the wrist to the shoulder, and may include a few spiea 
turns over the shoulder and about the chest to aid 
immobilization and oppose overriding. The fore- 
arm should be flexed and supported by a sling at 
the wrist. Snug support under the elbow in low 
fractures can produce an angular deviation inward 
of the lower fragment (Fig. 125), which greatly dis- 
. figures the limb, especially when the forearm is 
tion of shaft; angular extended ; this deformity is considered in detail in 
displacement; cubitus the subsequent section on Supra-condyloid Fractures. 
A posterior moulded plaster or wire splint, extend- 
ing under the forearm and over the back of the shoulder (Fig. 126), is 
convenient and efficient. A weight attached to the elbow is sometimes 
useful to prevent shortening or to overcome that which is already pres- 
ent ; it will lengthen a limb even after the lapse of two or three weeks. 
I have found it advantageous in eases o( tract lire by direct violence, 
especially in women and the alcoholic, to keep the patient in bed for 
about a week, or until the danger oi' acute inflammatory complications 



248 



FRACTURES. 



Fig. 127. 




Stromeyer's cushion applied. 



had passed. Stromeyer's cushion, designed particularly for the treat- 
ment of compound fractures, is useful as a support. It has the form 

of a triangular pyramid (Fig. 127), 
the long lines of which are twelve 
or. fifteen inches long. It should be 
firm enough to keep its shape uuder 
pressure, and its upper end should be 
blunter than shown in the figure. It 
is secured in place by tying the upper 
pair of straps about the opposite 
shoulder and the lower pair about 
the waist. A similar but smaller 
cushion (Fig. 128) is sometimes used 
in connection with an ambulatory 
dressing like the preceding. 
In the treatment of compound fractures the general principles laid 
down in Chapter VII. are to be followed. I habitually treat them in 
bed for the first fortnight with 

the limb on a pillow, trusting to Fig. 128. 

the position and the support of 
a bulky dressing of the wound 
for the desired immobilization. 
If prompt union of the wound 
is not obtained moulded splints 
can be applied outside the dress- 
ing. Resection of the ends of 
the fragments or their direct 
suturing is rarely indicated. 

When there is reason to fear 
serious injury to bloodvessels or 
nerves fixed dressings and band- 
ages should be avoided until 
after the extent of the injury 
shall have become apparent. 
Reduction should be made as 
completely as possible and the 
limb supported upon cushions. 

If there is reason to believe 
that the musculo-spiral nerve 
has been ruptured, it should be 
sought in the groove between 
the supinator and brachialis anti- 
cus and traced to the point of 
injury, and sutured. Or the 
operation may be delayed two or 

three weeks in order that repair may be well advanced and the dangers 
of infection thereby lessened. If the paralysis appears only after the 
lapse of a few weeks it is probably due to inclusion of this nerve in 
callus or cicatrical tissue, which must then be relieved by open opera- 
tion. (See Chapter VI., p. 76.) 




Small Stromeyer cushion for ambulatory 
treatment. 



FRACTURES OF THE HUMERUS. 249 

3. FRACTURES OF THE LOWER END OF THE HUMERUS. 

This group, like that of fractures at the upper end of the humerus, 
includes a number of varieties differing materially in character and 
importance, and having in common only their position near the elbow, 
and the frequent necessity and difficulty of making a differential diag- 
nosis between each and the others and dislocation. A certain lack of 
agreement among writers, as to the sense in which some of the distin- 
guishing terms are used, makes it desirable to define those that are to 
be here employed at the same time that the limits of the divisons of 
the main group are traced. These divisions are : 

A. Fractures Above the Condyles ; Supracondyloid. The line of 
fracture crosses the expanded part of the bone above the articular sur- 
face transversely or obliquely, and may or may not open the articulation. 

B. Fractures of the Internal Epicondyle or Epitrochlea. The line of 
fracture is entirely extra-articular, and the piece broken off consists 
of the whole or part of the epicondyle. And by the internal epicon- 
dyle or epitrochlea is meant the whole of the projecting tuberosity that 
lies above and on the inner side of the trochlea, and part of which is 
developed about a separate centre of ossification. 

C. Fractures of the External Epicondyle. The line of fracture is 
probably extra-articular; the fragment is very small, consisting of the 
epicondyle proper, either alone or with some of the adjoining bone. 

D. Fractures of the Internal Condyle. In these the line of fracture 
passes from a point on the inner border of the bone above the tip of the 
epicondyle obliquely downward and outward to the articular surface. 

E. Fractures of the External Condyle. Similar to the preceding 
variety, except that the line of fracture begins upon the outer side and 
passes downward and inward. 

F. Intercondyloid or T-shaped Fractures. These are a combination 
of the first, fourth, and fifth, the extremity being separated from the 
shaft and split into two or more pieces. 

G. Separation of the Epiphysis. The fracture follows the line of 
the conjugal cartilage. 

H. Fracture of the Articular Process. In this more or less of the 
portion of bone covered by articular cartilage is broken off; the most 
common form is fracture of the capitellum. 

These fractures are much more common than those of either the 
upper end or shaft. The relative frequency of the varieties mentioned 
in the preceding list has not been satisfactorily determined; published 
statistics differ quite widely, and the differential diagnosis is often so 
difficult (partly because of the extreme youth of many of the patients) 
that doubt must sometimes remain whether a case has been properly 
assigned to its class. In the Out-patient Department of the House 
of Relief in about six years, ending in 1904, 97 of these fractures, 
excluding the epicondyle, were received, as follows : External condyle 
45, supracondyloid 26, intercondyloid 9, internal condyle 15, separa- 
tion of epiphysis 1, edge of trochlea l. 1 

Examination of the record suggests that some of those classed as fracture* of the 
internal condyle were supracondyloid. Sixty-two of the patients were under eleven 
years of age, and IS others were loss than twenty years old; 15 were more than twenty 
years old. For other statistics, see Stolle, Deutsche Zeitschrift fur Chir.. vol. lxxiv. p, 65 



250 



FKACTUBES. 



The great relative frequency of these fractures in children makes 
necessary a brief account of the somewhat complex development of this 
end of the bone. According to Henle, the epiphysis at birth is wholly 
cartilaginous below a transverse line passing through the lower part 
of the olecranon fossa ; in a month or two this line descends centrally 
to the lower edge of the fossa, becoming convex, and during the first 

Fig. 129. 






Fig. 130. 



Twelfth to fifteenth year. Eighth to twelfth year. First to second year. 

Ossification of the lower epiphysis of the humerus. 

or second year a centre of ossification appears in the capitellum. 
Between the eighth and twelfth years this nodule enlarges, nearly or 
quite reaching the trochlear groove, a nodule 
appears in each epicondyle, and the diaphy- 
sis sends a prolongation down into the inner 
portion of the trochlea. Between the twelfth 
and fifteenth years the nodule of the capi- 
tellum unites with that of its epicondyle, 
and after that the final point of ossification, 
that of the trochlea, appears ; it is a thin 
concave cap or shell, closely applied to the 
downward projection of the corresponding 
portion of the diaphysis, and unites with 
the nodule of the capitellum about the fif- 
teenth year ; soon afterward the nodule 
formed by the union of the trochlea, capi- 
tellum, and external epicondyle unites with 
the diaphysis, and subsequently the nodule 
of the internal epicondyle unites. Kocher's 
statement, following Farabeuf, that the 
trochlear nodule is the first to unite with 
the diaphysis seems to be an error due to 
misinterpretation of the peculiar descent of 

the diaphysis into the trochlea, probably through ignorance of the late 
appearance of the trochlear nodule. It thus appears that the epiphysis 
after about the fifth year is an irregular strip of cartilage containing 
one, or two, bony nodules in its thicker outer portion, and none in its 
thin saucer-like trochlear portion, which latter is continuous by a sort 
of neck with the cartilaginous and bony internal epicondyle. My own 
specimens and skiagrams indicate that the end of the diaphysis after 
the sixth year is much more directly transverse, descends lower on the 
outer side, than is shown in Fig. 129. Possibly the difference in ap- 




Supracondyloid fracture of the 
humerus. 



FRACTURES OF THE HUMERUS. 



251 



pearance depends upon the direction of the line of section, Henle carry- 
ing it further forward on the outer side so as to include more of the 
projecting capitellum. 

A. Fractures Above the Condyles — Supracondyloid. 

The line of fracture may be transverse or oblique, and oblique 
either from side to side or from before backward, and it may open 
the joint by crossing the olecranon or coronoid fossa or by the 
extension into it of a fissure between the condyles. It may lie above 
both epicondyles, or above one and below the other, and, at least at an 
early age, may coincide in whole or in part with the epiphyseal line. 

The cause is violence acting upon the front or back of the lower 
end of the bone, usually through the bones of the forearm, as in a fall 
upon the outstretched hand, or, as indicated by KocheFs experiments, 
by torsion. The commonest cause appears to be a fall upon the hand 
in which the end of the humerus is pressed backward (" extension 
fracture ") either directly by the partly flexed forearm or possibly by 
hyperextension of the joint. In this case the line of fracture is 
oblique from behind downward and forward, the lower end of the 
upper fragment often ending in a sharp point on its anterior aspect. 



Fig. 131. 



Fig. 132. 





" Extension" and " flexion " fractures of lower end of the humerus. 

When the force acts in the opposite direction, against the back of the 
elbow, a much more rare occurrence, and the lower end of the humerus 
is forced forward (" flexion fracture "), the line of fracture runs from 
in front downward and backward, and the sharp point is found at the 
upper end of the lower fragment in front (Figs. 131 and 182). Figs. 
133 and 184 represent a specimen of this kind which 1 obtained from 
a patient who died of delirium tremens shortly after the accident. 
While carrying a flagstone he fell upon the elbow, flexed at a right 
angle, with the edge of the stone resting in the flexure of the joint ; 
the fracture was almost exactly in the frontal plane, as it' the condyles 
had been cut oil' by an axe descending along the anterior surface of 



252 



FRACTURES. 



the humerus. Iu both forms the higher the fracture the less, appa- 
rently, is the obliquity. An adduction fracture in the young may be 



Fig. 133. 



Fig. 134. 




Supracondyloid fracture. A. Front. B. Rear view. 

classed as a low form of this ; the fracture starts close above the exter- 
nal epicoudyle and runs along or close above the epiphyseal line 
toward or to the epitrochlea or diverges 
downward through the trochlea into the Fig. 135. 

joint (Fig. 135) ; the displacement is angu- 
lar, pivoting on the inner side, and if it 
remains uncorrected or recurs, marked 
cubitus varus results. 

The character and extent of displace- 
ment vary with the direction of the line 
of fracture ; as the latter is so often oblique 
downward and forward, the lower frag- 
ment is commonly displaced backward 
and upward, and not infrequently the 
sharp end of the upper fragment is forced 
through the overlying muscles and even 
the skin on the antero-internal aspect. In 
one case, seen six months after the accident, 
I found on operation the musculospiral 
nerve ruptured at the edge of the upper 
fragment. To this displacement backward 
may be added, or for it may be substituted, 
an angular displacement, the apex directed 
forward, which accentuates the promi- 
nence of the back of the elbow. In the 
less common cases in which the obliquity 

is downward and backward the displacement of the fragment is for- 
ward and upward, but is much less marked than in the other form, 
although occasionally the upper fragment has been forced through the 
triceps and the skin. If displacement persists the range of motion in 




Experimental adduction fracture 
in a child. 



FRACTURES OF THE HUMERUS. 



253 



the elbow may be restrieted by direct bony contact or by fibrous bands 
attaching the torn and bruised muscles to the bone. 

In the low fractures in children, where the line apparently often 
coincides more or less with the epiphyseal junction, the lower frag- 
ment may be displaced inward, or less frequently outward, and with 
the inward displacement usually coexists an angular displacement by 
which the outer portion of the lower fragment is lowered, and some- 
times a backward displacement of its outer portion. The result of this 
displacement, if uncorrected, is the angular lateral deviation of the 
lower fragment with the apex directly outward, which is shown in 



Fig. 136. 



Fig. 137. 



Supracondyloid fracture with angular di 
placement ; marked cubitus varus. 



Supracondyloid fracture with angular displace- 
ment ; marked cubitus varus. Front view. 



Figs. 136 and 137 and in Plates VIII and XII. The deformity of the 
elbow, cubitus varus, which results is very noticeable in extension and 
has usually been attributed solely to the ascent of the internal con- 
dyle after its fracture ; but the almost total absence of such specimens, 
the possession of others showing descent of the external condyle, and 
the findings in several operations undertaken to correct the deformity 
have convinced me 1 that, when marked, it is habitually the result of a 

1 Stjnison : Cubitus varus, Annals .if Surg., Sept., L900, 



254 



FRACTURES. 



complete or partial supracondyloid fracture followed by this angular 
displacement, and that this is practically the only form of fracture after 
which it is at all likely to occur to any extent. A number of speci- 
mens have been described and I possess three (Figs. 125, 136 and 
137, and Plate VIII.) ; those represented in Fig. 137 and Plate VIII. 
correspond almost exactly with the condition of the bones shown in 
the skiagram (Plate XII., Fig. 1) of a limb very like Fig. 138. 

Two frontal sections of the specimens shown in Plate VIII. show no 
trace of fracture, no change in the cortex of the juxta-epiphysary 
region, and the outline of the inner supracondyloid ridge is unbroken, 
but more sharply curved. The appearance is that of elongation on 
the outer side, and of shortening on the inner, and suggests a frac- 

Fig. 138. 




Cubitus varus. 

ture along or close above the epiphysary line, incomplete on the inner 
side, with angular displacement upon the inner portion of the internal 
condyle as a centre. Presumably the mass between the outer condyle 
and the shaft is new bone formed by the untorn periosteum. Ex- 
periment on the cadaver shows that the posterior part of the periosteum 
may remain untorn even when the displacement downward of the outer 
part of the fragment is considerable, and its preservation is even greater 
when the fracture is along or close to the epiphyseal line. 

The artery or the median or musculo-spiral nerve may be torn or 
compressed, but this injury is much less frequent than might be antici- 



PLATE VII 




Fig. 1.— Skiagram of Normal Elbow at age of Five Years. 




Fig. 2. — Normal Epiphysis of Humerus at age of Eight Years. 



PLATE VIII 

FIG. 1 FIG. 2 





FIG. 3 




Cubitus Varus after Low Partial Supracondyloid Fracture in Youth. 

or Separation of Epiphysis. 

Fig. 1, front. Fig. 2, rear. Fig. 3. sections, ending above on posterior surface. 



PLATE IX 




Ficr. 1.— Fracture of the Lower End of the Humerus. 




Fig. 2. — Supracondy loid Fracture of the H 



PLATE XI 




Fig. l.-Supraeondyloid Fracture of Humerus by Extension in a Young Child. 




Fig. 2. — Supracondy loid Fracture at Eight Years. 



PLATE XII 




Fig. 1.— Old. Supraeondyloid Fracture of trie Humerus, Cubitus Varus, 




2.— Cubitus Varus; Three Years after a Low Supraeondyloid Fracture. 
The lower part of the Supinator Ridge ha* been cut awa\ 



FRACTURES OF THE HUMERUS. 255 

pated from the extent and direction of the displacement. In one case 
six months old I found the mnsculospiral nerve ruptured at the dia- 
physeal edge of the fracture, and sutured it. The ultimate result is 
not known. 

In two cases of inward displacement of the low form in the young 
I have seen late sloughing of the skin by pressure against the outer 
angle of the upper fragment. Savariaud l reports four cases of appa- 
rent injurv to the median and ulnar nerves ; one recovered spontane- 
ously, one after operation, and in two operation failed to relieve. 

Symptoms. The symptoms are deformity, loss of function, abnormal 
mobility, and pain. The deformity may be marked or slight, the 
former especially when the line of fracture is oblique from behind 
downward and forward and the lower fragment is displaced and tilted 
backward ; this causes a prominence of the back of the elbow which 
in some stages resembles that of a dislocation, but is readily distin- 
guished from it by noting that the relations of the olecranon and epi- 
condvles are normal and that the head of the radius is in place. In 
the young, when the line of fracture passes below the internal epicon- 
dyle and the lower fragment is displaced inward, the appearance on 
the inner side is that of an internal lateral dislocation, and the true 
nature of the injury must be determined by the relations of the head 
of the radius and the capital 1 urn. The easy reduction of the backward 
displacement by drawing the flexed forearm forward, and its easy 
reproduction by pressing the forearm backward has led even expe- 
rienced surgeons into error, and emphasizes the necessity of accu- 
rately determining the relations of the head of the radius and the 
capitellum. 

The determination of these relations is the first step to be taken in 
the examination of most injuries of the elbow ; it is conveniently done 
by placing the tips of the thumb and middle finger on the two epicon- 
dyles respectively and that of the index-finger upon the point of the 
olecranon, and noting their correspondence or lack of correspondence 
with the normal in the positions of extension and of flexion at a right 
angle, ordinarily using the other elbow in comparison. The head of 
the radius can be felt from one-half to three-fourths of an inch distant 
from the external epicondyle in the direction of the wrist. 

Swelling is marked and uniform ; eeehymosis is usually present after 
a few hours; voluntary motion is inhibited by pain, passive motion 
restricted. Abnormal lateral mobility — adduction and abduction of 
the forearm — exists and is most surely recognized if the test is made 
while the elbow is extended. If the condyles are firmly grasped with 
one hand and the shaft with the other, free mobility of one upon the 
other, usually with crepitus, is found. Pressure upward with the hand 
under the flexed elbow causes pain. Pressing the condyles together 
does not cause pain unless the line of fracture also runs between them 
(T-fracture), nor can the condyles be moved independently of each 
other. Pressure with the tip of the finger along the supracondyloid 
ridges may detect irregularity and cause pain at the point of fracture 
if the displacement is slight ; if it is marked the lower end of the 

1 Savariaud: Arch. gen. de mod., 1903, No. 2. 



256 FRACTURES. 

upper fragment can be readily recognized, usually in front, at or close 
above the flexure of the elbow. Kocher, analyzing five personal cases 
of what he terms fr actum diacondylica, which corresponds to that 
described here as the low form in the young, speaks of pain on pressing 
the extended or flexed forearm against the arm. 

Treatment. In view of the proximity of the joint the important indi- 
cation is to secure repair without displacement ; and the displacements 
which threaten are the primary overriding in the higher fractures in 
adults and the late lateral angular deviation in the low ones in children 
(Fig. 136). The overriding can be corrected by traction, preferably 
with the elbow at a right angle, and its recurrence effectively opposed 
by anterior and posterior moulded splints, or a plaster encasement, 
aided sometimes by a weight attached to the forearm close by the 
elbow, with the wrist supported by a sling. 

In the low form in children, which is, I believe, practically the 
only form of fracture at the elbow in which the dreaded deformity, 
cubitus varus, is liable to ensue, the principal factor in its production, 
after reduction of the primary displacement, is, I think, the action of 
gravity when the forearm is supported across the front of the body. In 
experiments upon the cadaver and in operations to correct the deform- 
ity I have repeatedly seen the displacement appear when the limb was 
placed in this position, and I have seen one patient in whom it seemed 
probable that it took place within a plaster encasement, although it 
is not certain that reduction was made and maintained during the 
application of the dressing. Recumbency, with the elbow at a right 
angle and the forearm vertical, has always, in my experience, prevented 
it, with the aid of a thick enveloping dressing of gauze rollers. The 
confinement to bed need not last more than a week. 

Full 'flexion of the elbow, which of late has been urged in a some- 
what exaggerated and uncritical way as the proper treatment for all 
fractures at the elbow, undoubtedly holds the fragments, in this form of 
fracture, more firmly together, apparently by the tension of the triceps 
thus produced, or, as emphasized by Lusk, 1 by the untorn periosteum 
on the back of the bone, but it can itself produce an angular displace- 
ment (apex backward), as shown in Plate XVI., and of course it is 
valueless unless antecedent reduction is made. 

The frequency with which some deformity persists after this fracture 
has led some surgeons to maintain that in it, more perhaps than in any 
other simple fracture of a long bone, a primary operation for adjust- 
ment and fixation is justifiable or even requisite, but Konig 2 has shown 
by several skiagrams taken at intervals of two or three years that even 
very marked deformity disappears rapidly in the young by absorption 
of projecting bone and the filling up of hollows, and that functional 
limitations are rarely caused by it. 

In compound fractures I always use vertical suspension of the limb 
for about a fortnight, unless the wound heals sooner. It is of great 
value in controlling reaction as well as preventing gross displacements ; 

1 Lusk : Annals of Surgery, 1908, vol. 48, p. 432. 

2 Konig : Arch, fur Klin Chir., vol. 85, p. 187. 



FRACTURES OF THE HUMERUS. 257 

minor adjustments can still be made after the wound has healed or lias 
become unimportant. 

In several cases of low fracture in the young, after the lapse of from 
four weeks to six months, I have exposed the region through an exter- 
nal lateral incision, cut away all new bone, freed the lower fragment, 
and brought it back into place with full restoration of form and func- 
tion. Occasionally a second incision on the inner side is needed. In 
some old cases the deformity has been relieved by excision of a wedge- 
shaped piece from the outer side of the humerus just above the 
epicondyle, thus bringing the lower fragment into line with the shaft. 
The same could be done in case of angular displacement, apex forward, 
and thereby the hand would be brought nearer the shoulder in full 
flexion of the joint. 



B. Fractures of the Internal Epicondyle (Epitrochlea). 

By the epitrochlea is meant the projecting spur of bone on the side 
of the trochlea ; its lower limit is sharply defined, but above it is con- 
tinuous with the condyloid ridge. 

The first author who called attention to this fracture was Granger, 1 
in 1818. It is more common in children than in adults ; often cases, 
not associated with dislocation of the elbow, treated in the House of 
Relief in two and a half years, the ages were one, five, ten, ten, four- 
teen, seventeen, twenty-eight, thirty-four, and forty-three years. The 
fracture frequently accompanies dislocation of the elbow, being pro- 
duced, I think, by the pull of the flexor muscles of the forearm which 
are attached to it and which are put upon the stretch by the forcible 
abduction of the form which is so common a first step in 
the production of a backward or outward dislocation. In FlG 
cases not thus complicated the cause appears commonly 
to be external violence acting directly upon the back of 
the epitrochlea. 

Symptoms. The symptoms vary somewhat with the 
size of the fragment, for when the latter is small it is held 
in place by the untorn portion of the muscular attach- 
ments upon it and the adjoining bone, but when it is large 
enough to include the greater part of the attachment dis- 
placement takes place downward and forward in the direc- 
tion of the muscles. If the swelling is not too great the 
fragment can be seized between the thumb and finger and 




moved, usually with crepitus. Ecchymosis is common, 

and the functions of the joint may be diminished bv pain Fracture of the 

or the fear of it. Pain is felt on forcible contraction of intenml epicon " 

,1 m i" ,i i i dvleoi the hume- 

the flexors of the hand. rus (epitrochlea). 

In a few cases the ulnar nerve has been injured bv the (Gtolt.) 
original violence or irritated by pressure of the displaced 
fragment or a portion of callus. In three of Granger's cases there was 
partial paralysis of motion and sensation in the region supplied by the 

^ 3 Granger: Edinburgh Medical and Surgical Journal, vol. xiv. p. 196, 



258 FRACTURES. 

ulnar nerve, and repeated crops of vesicles formed upon the correspond- 
ing part of the hand during the two or three months following the 
injury. All the symptoms disappeared after a time. Richet 1 observed 
a case of fracture of the epitrochlea with dislocation of the elbow in- 
ward due to a fall upon the ice. After reduction of the dislocation the 
ulnar nerve was found to be completely paralyzed. A month later the 
little finger was so insensitive that the patient amused himself and 
amazed his play-fellows by holding it more than a minute in the flame 
of a candle. The deep burn which was the result took several weeks 
to heal; afterward sensibility returned gradually and became complete. 
Denuce 2 was consulted by a man suffering with an intense neuralgia 
of the ulnar nerve following a fall upon the elbow three months before. 
He recognized deformity of the epitrochlea, made an incision, and 
found the nerve hypertrophied and resting upon a bony prominence 
formed by the epitrochlea displaced and united in its false position. 
The projecting part of the bone was excised, and the neuralgia ceased. 
Treatment. The treatment is simple : immobilization of the elbow 
in the flexed position so as to relax the muscles that arise from the epi- 
trochlea and thus diminish the force that tends to draw it forward and 
downward. It is futile to attempt to keep the fragment in place by 
pressure upon it from the outside. Even if it remains displaced down- 
ward and forward the deformity is slight and entails no loss of function. 
Immobilization should be maintained until consolidation has taken 
place, the length of time necessary for which varies with the age of the 
patient and the extent of the unreduced displacement. In children, 
and without displacement, union is sufficiently firm at the end of ten 
days or a fortnight to allow splints to be laid aside and the arm to be 
carried in a sling, and in three Aveeks the arm may be left unsupported 
and free. 

In a few cases the fragment has been excised because of pain or tear 
lest it should interfere with function ; it has also 
Fig. 140. been proposed to secure it in place by transfixion 

with a pin or by incision and suture, but the meas- 
ure seems wholly unnecessary. 

C. Fractures of the External Epicondyle. 

This is a much rarer accident than the preceding, 
and as the fragment that is broken off is small, and 
as the cause appears to be always direct violence, 
which is usually accompanied by bruising and 
swelling, the exact nature of the injury may easily 
pass unrecognized. An anatomical demonstration 
of the fracture has never been made, except in con- 
Fracture of the external nec ti n with more extensive fractures of the elbow. 

epicondyle of the hume- T ,, , . , , . , -, ,, 

rus. (Gurlt.) I n the sense in which the term is here used the 

epicondyle is the small prominence above and on 

the outer side of the capitellum, composed in part of bone formed about 

1 Richet : Anatomie Medico-Chirurgicale, 4th ed., p. 672, note. 

2 Denuce : Diet, de M£d. et (Jhir. Pratiques, art. Coude, p. 721. 




FRACTURES OF THE HUMERUS. 259 

a separate centre of ossification, and in part of the projecting portion 
of the shaft or condyle itself. To it are attached the external lateral 
ligament of the joint and part of the extensor muscles of the forearm. 

Most surgeons deny the possibility of an extra-articular fracture of 
this part, and group all fractures of the region as of the external coudyle. 
Anatomically speaking it is certainly possible for such a fracture to in 
occur; the epicondyle, though small, is still large enough to be broken in 
such a way that the line of fracture may lie entirely outside the joint. 

Gurlt describes as extra-articular fractures of the external epicon- 
dyle two specimens preserved, the one at Giessen, the other at Berlin. 
In each the fracture has united with considerable displacement down- 
ward of the fragment, which appears in the description and figure (Fig. 
140) too large to have been entirely extra-articular. Still, his personal 
examination of the specimens was more likely to lead to a correct 
opinion of them than a verbal description or a figure is. 

There is little to be added. The cause must be direct violence, or 
possibly forcible adduction of the forearm acting through the lateral 
ligament ; the displacement must be slight and unimportant ; the 
treatment, rest. 

D. Fractures of the Internal Condyle. 

The line of fracture runs from a point on the inner border of the 
epitrochlea or of the ridge above it downward and outward, ending on 
the outer half of the lower part of the trochlea or at, or even a little 
beyond, its junction with the capitellum (Fig. 141). 

The common cause appears to be violence acting from below upward 
upon the trochlea, as in a fall upon the flexed elbow or by forced adduc- 
tion or abduction of the forearm, turning 
upon the head of the radius as a centre, and Fig. 141. 

breaking off the condyle by forcing it up- 
ward or backward or drawing it downward 
or forward. 

The fragment may be displaced in any of 
these directions, and may also be rotated. 
As the ulna remains attached to the frag- 
ment and is itself held in place by its attach- 
ments to the radius, the displacement of the 
fragment cannot be great unless there is 
associated dislocation of the radius from the 
capitellum, as occasionally observed. A 
late displacement, similar in effect to that 
observed after supracondyloid fracture, may 
occur here also; pressure upward against 
the flexed elbow, as by a snug sling, is 
transmitted through the olecranon to the 
fragment and raises it above its proper place, thus changing the direc- 
tion of the transverse axis of the joint and substituting abduction of 
the forearm — cubitus varus — for the slight normal abduction. Possibly 




Upper and lower limits of fracture 
of the internal condyle. 



260 FRACTURES. 

the contraction of the triceps and brachialis anticns may aid in pro- 
ducing this result, I believe, however, this is a much less frequent 
cause of the deformity than displacement after supracondyloid fracture. 

The swelling, as in most of these fractures at the elbow, is uniform, 
rarely more marked on the side of the injury except at first; loss of 
function is marked, the arm generally being held at an angle of about 
125 degrees, and the range even of passive motion without anaesthesia 
is restricted. The characteristic symptoms are independent mobility 
of the condyle, usually with crepitus, pain on pressing the condyles 
together and on pressure with the tip of the finger at the point where 
the line of fracture crosses the supracondyloid ridge, and sometimes an 
irregularity in the line of the ridge at that point. The independent 
mobility is recognized by grasping the fragment between the thumb 
and fingers and moving it slightly backward and forward while the 
other condyle and the shaft are held with the other hand. Pain can 
also be caused by pressure upward against the olecranon or backward 
through the forearm while the elbow is partly flexed. If the limb can 
be fully extended abnormal lateral mobility of the forearm — adduction 
and abduction — is found, especially abduction. The same mobility 
exists when the joint is more or less flexed, but the observation cannot 
be safely made, at least in the young, because of the difficulty of dis- 
tinguishing between it and rotation of the humerus ; full extension is 
necessary for the test, and this can rarely be had except with the aid 
of general anaesthesia. The relations of the epitrochlea and tip of the 
olecranon are preserved, and their elevation or displacement backward 
with reference to the external epicondyle is generally too slight to be 
recognized through the swelling. 

Associated dislocation of the radius from the capitellum is recognized 
by the presence of its head below and behind the outer condyle and by 
the marked displacement backward of the internal condyle, and olecra- 
non which leaves the outer condyle and lower end of the shaft as an 
easily recognizable prominence in the flexure of the joint. 

The main point to be considered in the treatment is the correction or 
prevention of such displacement as would seriously interfere with the 
functions of the joint or the appearance of the limb, notably the ascent 
of the condyle by which the axis of the forearm would be directed 
inward (adduction). The fragment is too small to be acted upon 
directly by any dressing, and its position must, therefore, be controlled 
through the ulna to which it is attached. Ordinarily this can be satis- 
factorily done by a fixed dressing with the elbow at a right angle, either 
a tin posterior splint or, preferably, a moulded one or a plaster encase- 
ment. The essential points are that the fragment should be kept well 
down in place while the dressing is hardening, if a moulded one is used, 
and that it should not be pressed upward during repair by the bandage 
which supports the forearm ; this should lie near the wrist, not under 
the elbow. Full flexion and full extension of the joint, which meas- 
urably control the position of the fragment by the tension of the pos- 
terior and anterior portions of the capsule respectively, have been 
recommended ; in each position tilting of the fragment sometimes 



PLATE XIII 




Fracture of Internal Condyle of the Humerus 
in an Adult. 



> 

> — I 

X 

w 

< 
Ph 





PLATE XV 




Fracture of External Condyle; Patient Eighteen Years Old. 



PLATE XVI 



FIG. 1 




Angular Displacement Produced by Flexion. 



FIG. 2 




Discondyloid Fracture, Three Weeks Old. 
Reduced by operation. 



FRACTURES OF THE HUMERUS. 



261 



Fig. 142. 



occurs. Full flexion is a much more convenient attitude than full 
extension, unless the patient is kept in bed; but it is no more con- 
venient than rectangular flexion and, I think, gives no more security 
against displacement. It is usually desirable in fracture complicated 
by dislocation of the radius, in order to oppose recurrence. 

If the fragment is rotated or tilted and cannot otherwise be brought 
into place, it should be exposed by an incision ; advantage may be taken 
of this to fix the fragment in place by periosteal sutures or even by 
transfixion with a pin. 

Immobilization is required for about three weeks, a sling for another 
week, and then the limb abandoned to natu- 
ral use without forced passive motion; the 
latter, for reasons given in Chapter VII., is 
more likely to do harm than good, for it 
may increase the irritation which provokes 
overgrowth of callus. Even with satisfac- 
tory reduction the range of motion may be 
diminished by callus obstructing the olecra- 
non or coronoid fossa, and even with con- 
siderable permanent displacement the range 
of motion may be only slightly restricted. 

E. Fractures of the External Condyle. 

These are much more common than frac- 
tures of the internal condyle, and much 
more frequent in the young than in adults. 
The cause is a fall upon the hand while the 
elbow is flexed or upon the inner and pos- 
terior portion of the flexed elbow, or forcible 
adduction of forearm ; in the first the force is transmitted through the 
radius to the capitellum in a backward or backward and upward direc- 
tion, in the second through the olecranon upward and outward against 
the outer slope of the trochlea, and in the third it acts by avulsion 
through the external lateral ligament and the muscles attached to the 
condyle. I have found it easy to produce the fracture by adduction of 
the extended forearm in bodies of the young, or by a blow upon the 
palm with the elbow flexed at a right angle (Fig. 143). In one or 
two cases I have thought the cause was a blow upon the back of the 
condyle. 

The line of fracture runs obliquely from the outer ridge of the 
humerus above the epicondyle downward and inward into the joint, 
ending usually in the groove of the trochlea, coinciding in part at least 
with the epiphyseal line so that the fragment comprises the capitellum, 
the outer portion of the trochlea, and perhaps the epicondyle. In the 
adult the line seems usually to extend somewhat higher. As the 
fragment remains attached to the radius and ulna by the lateral ligament 
and capsule, the displacement is usually slight when the forearm is 




Lines of fracture of external 
condyle 



262 



FRACTURES. 



Fig. 143. 




Experimental fracture of external con- 
dyle by a blow on tbe palm of the 
hand, elbow flexed at right angle. 

Swelling appears first on 
the outer side and then be- 
comes uniform; ecchymosis 
appears below the condyle, 
or on the inner side if the 
patient has remained in 
bed with the arm abduct- 
ed. Loss of function is 
not so marked as in frac- 
ture of the internal con- 
dyle ; pain is felt on press- 
ing the broken condyle 
against the shaft, inward, 
upward, or forward; also on 
pressure with the tip of the 
finger on the ridge close 
above the epicondyle. Ab- 
normal mobility appears 
as adduction of the fore- 
arm (also painful), with less 
or no abduction, and can 
sometimes be recognized 
by grasping the fragment 
between the thumb and 
finger and moving it back- 
ward and forward while the 
shaft; is firmly held ; crepi- 



m its proper position, but there is tend- 
ency to tilting (flexion) of the fragment, 
and sometimes it is markedly rotated 
about one or another axis, so far in one of 
Kocher's cases and one of mine that the 
fractured surface looked outward, and in 
two of mine upward. If the forearm is 
abducted the fragment is displaced back- 
ward or upward and outward ; if adducted, 
forward or doAvnward. If the elbow is 
simultaneously dislocated backward or 
outward the fragment accompanies the 
radius. 

A late condition, sometimes found, such 
as that shown in Fig. 145, and usually 
attributed to a primary displacement left 
uncorrected, appears to me to be due more 
probably to arrest of development at the 
base of the capitellum. This condition 
leads to marked abduction of the forearm 
cubitus valgus. 

Fig. 141. 




A 



Old fracture of external condyle of humerus with displace- 
ment downward and inward and incomplete dislocation 
inward of ulna. 



FRACTURES OF THE HUMERUS. 263 

tus may be perceived at the same time. If the fragment is notably 
displaced the irregularity may be recognized by palpation ; and if the 
ulna is at the same time dislocated backward from the trochlea the con- 
dition is recognized by noting the common signs of dislocation on the 
inner side — backward projection of the olecranon, prominence of the 
trochlea in the flexure of the elbow — and the position of the fragment 

Fig. 145. 




Fracture of external condyle ; late result. Cubitus valgus. (Helferich.) 

in close relations with the head of the radius behind and above its 
proper position. The much rarer dislocation outward could be recog- 
nized in like manner. 

The difficulty in treatment lies more in the reduction of displacement, 
if it is marked, than in the maintenance of the proper position if that 
is secured. In most cases, those without much displacement, immobil- 
ization for three weeks at a right angle by a posterior moulded splint 
is sufficient, although, of course, pains must be taken to make reduc- 
tion as complete as possible. 

When the fragment has suffered one of the rarer displacements by 
rotation it is generally impossible to restore it to place without an 
operation. In three such cases I opened the joint by an incision on the 
outer side and, with considerable difficulty in two, turned the fragment 
back into place and obtained a good result. Kocher twice excised the 
fragment under such circumstances, and reports a satisfactory result ; 
both were old cases, and one of mine was two months old. 

In two old cases, one of them with displacement o\' the fragment 
downward and inward and partial dislocation of the ulna inward, the 
other with displacement upward and backward, I detached the frag- 



264 



FRACTURES. 



merit with a chisel and brought it back into place. Primary union ; 
considerable improvement in function. 

F. Intercondyloid, T-shaped, or Y-shaped Fractures. 

These fractures are commonly caused by great violence, and conse- 
quently are often compound, either by the direct action of the violence 
upon the skin or from within outward by the sharp end of one of the 
fragments. 

In many the main line of fracture is the same as in supracondyloid 
fracture, with an additional line passing down into the joint between 
the condyles ; in the others the variations in the form and extent of the 



Fig. 146. 



Fig. 147. 





Intercondyloid fracture of the humerus. 
(Gurlt.) 



Intercondyloid fracture of the humerus. 
Front view. (Gurlt.) 



fracture and the degree of displacement are very great, the essential 
features being the separation of both condyles from the shaft and from 
each other, the variations appearing in the number and position of the 
fragments and lines of fracture. When the fracture between the con- 
dyles is a mere fissure the condyles remain together, and the displace- 
ments are those of supracondyloid fracture ; in the other cases the 
displacements are too varied and irregular for classification and the 
condyles may be widely separated from each other, the olecranon pass- 
ing up between them. 

Occasionally the nerves or vessels crossing the front of the joint are 
torn or compressed. 

Symptoms. The symptoms in many cases are those of supracondy- 
loid fracture with, in addition, independent mobility of the condyles 
upon each other and pain when they are pressed together. In cases 
with the more varied displacements the deformity is great and the inde- 
pendent mobility of the condyles upon each other and the shaft is 
readily recognized if they can be grasped through the swollen tissues. 



FRACTURES OF THE HUMERUS. 205 

In respect of treatment much that lias been said of that of supra- 
condyloid fracture can be repeated. Cases with comminution and much 
displacement are quite certain to result in marked limitation of motion 
in the joint. Reduction by manipulation through the unbroken skin 
is largely problematical, and the limb should, therefore, be kept in the 
attitude which will be most useful if stiffness results. In maintaining 
reduction I have been best satisfied with plaster splints, anterior and 
posterior, held snugly at and above the condyles while they were hard- 
ening. Vertical suspension occasionally does well, especially in com- 
pound fractures, but I have never continued its use for more than about 
ten days, resorting then to moulded splints with the elbow flexed, and 
with fresh reduction if necessary. There is of late a distinct tendency 
toward operation in such cases with the object of suturing or pinning 
the fragments in place, but it must be remembered that an ideal restora- 
tion is far from always producing a similar restoration of function. 

In compound fractures it may sometimes be advisable to remove some 
of the smaller fragments or cut off sharp ends ; and in one case in 
which the fragments could not otherwise be held together I transfixed 
them with a long drill which was left in place for a fortnight. Kocher 
recommends the removal of the external condyle, on the ground that it 
facilitates drainage and ensures a greater range of motion without seri- 
ously diminishing the stability of the joint. Occasionally it has seemed 
advisable to remove both condyles ; the resulting joint is likely to be 
troublesomely loose, although not so much so as when the olecranon 
also has been removed. 

G. Separation of the Epiphysis. 

To the account of the development of the epiphysis previously given 
(p. 250) must be added that the views of others differ therefrom in 
some important details, and that some of the appearances shown on 
section can be explained only on the supposition that the development 
(especially of the trochlea) differs widely in individuals, or (which seems 
to me more probable) that the sections have been made in different 
planes. The accounts which seem most trustworthy represent the 
trochlear portion of the epiphysis as remaining wholly cartilaginous 
much longer than the other portions, and as having a concave upper 
surface which steadily deepens so that before its union with the diaph- 
ysis it has become a relatively thin saucer-like scale capping a project- 
ing portion of the shaft, and is connected with the capitellum on one 
side and with the epitrochlea on the other only by a thin neck. This 
seems to make the separation of the entire epiphysis, with or without 
the epitrochlea, in one piece from the shaft very improbable except at 
an early age ; that it has thus been separated is demonstrated by a few 
specimens, but the diagnosis in the great majority of supposed cases 
rests only upon doubtful clinical evidence. Moreover, some writers 
and reporters of cases describe under this title fractures in which the 
line diverges widely into the shaft on the inner side, and 1 believe that 
all the eases are essentially the same as those described above as low 
supracondyloid fractures in the young. 



266 FRACTURES. 

Among the specimens described are Lange's, 1 two of Bardenheuer's, 2 
and two figured and described by Poland 3 from the museums of St. 
Mary's and St. Thomas's hospitals ; in Lange's the patient was ten 
years old, the separation (compound) was wholly through cartilage, 
and the epicondyles Avere separated from the fragment and also 
from the shaft ; the fragment w r as widely displaced from the shaft 
and the bones of the forearm, but was still attached to the shaft by the 
loosened periosteum. In one of Bardenheuer's the separation appears to 
have been below both epicondyles, and the fragment was displaced back- 
ward and inward with the forearm ; in the second the fragment, which 
is not described in detail, was displaced backward, also preserving its 
relations with the bones of the forearm. In both of Poland's the separa- 
tion was wholly along cartilage, the epicondyles remaining attached to 
the trochlea and capitellum. A specimen apparently of pure cartilag- 
inous separation was in the Bellevue Hospital Museum, but has now 
been lost. 

The cause appears usually to have been a fall upon the elbow or 
the outstretched hand ; in Lange's the elbow was caught between an 
elevator and a beam, and in one of Poland's it was "jammed in a 
gate." 

The displacement in all the certain cases has been great, and in all 
but Bardenheuer's the injury was compound. In the alleged cases 
diagnosticated without direct examination of the fragment the displace- 
ment has been sometimes marked, sometimes slight, the diagnosis in 
the former being made by palpation of the fragment, in the others upon 
the abnormal lateral and antero-posterior mobility of the upper end of 
the forearm with fine crepitus and on the exclusion of other forms of 
fracture. Schuller and Bruns think the injury more frequent than the 
paucity of reported cases indicates, an opinion which must be correct 
if the low supracondyloid fractures iu the young are included. 

The symptoms and diagnosis are essentially those of low supracon- 
dyloid fracture in the young. The line of separation may pass above 
or below the epicondyles ; the essential diagnostic feature (from dislo- 
cation) is the maintenance of the relations of the small lower fragment 
with the radius and ulna ; and the position of the line of separation 
along the epiphyseal junction may be indicated by cartilaginous crep- 
itus on manipulation. 

The treatment is reduction of the displacement and immobilization, 
with special precautions against displacement inward, as in low supra- 
condyloid fracture (q. v.). 

H. Fractures of the Articular Process, in Whole or in Part. 

These include fractures of the whole or part of the capitellum, of the 
inner portion of the trochlea, and of the capitellum and trochlea together. 

A few specimens of fracture in adults passing wholly or mainly 
below the epicondyles are known, and Kocher, who includes them with 

1 Lange : Medical Eecord, July, 1880, p. 48. 

2 Bardenheuer : Deutsche Cliirurgie, Lief. 63a. p. 736. 

3 Poland: "Traumatic Separation of the Epiphyses," London, 1898. 



FRACTURES OF THE HUMERUS. ( 2()7 

separation of the epiphysis under the title " fractura diacondylica," 
found that the lesion could be produced experimentally by a blow upon 
the lower surface of the bone in the direction of its long axis ; as the 
trochlea and capitellum project in front of the line of the shaft they 
can thus be broken off and pressed upward. (Compare Fig. 133.) In 
the alleged cases in the young the diagnosis must remain in doubt, for 
the cartilaginous element makes the arrays ineffective, and palpation is 
necessarily uncertain. 

The direction and character of the violence apparently concerned in 
the production of these fractures suggest a well-marked displacement 
of the fragment forward and upward in combination with the radius 
and ulna which probably could be recognized by palpation and the 
abnormal mobility. The indications for treatment would be to press 
the fragment downward and backward into place and keep it there by 
pressure or traction upon the upper part of the forearm. The prog- 
nosis, in respect of the preservation of function, seems bad because 
of the intra-articular position of the line of fracture. 

Fracture of the capitellum alone, in whole or in part, has been ob- 
served in a number of cases. Hahn 1 reports an old specimen in 
which the capitellum had united with the front of the humerus after 
displacement upward and rotation. Kocher figures four specimens 
representing larger or smaller portions of the capitellum removed by 
operation in fresh cases; Figs 149 and 150 represent the largest and 
smallest. Steinthal 2 reports a case similiar to Hahn\s. The capitellum 
was removed by operation, with improvement of function. 

In two of Kocher' s cases the cause was violence exerted through 
the radius, the elbow being flexed, once in a fall upon 
the palm of the hand, and once by pressure against the Fig. 148. 
palm while the back of the elbow rested against a wall ; 
in the other two the injury was received in an effort to 
raise or hold a heavy object, apparently with the elbow 
partly flexed. The mechanism in the latter cases seems 
to me to be pressure by the head of the radius upward 
against the lower anterior portion of the capitellum 
under the pull of the biceps. 

In a personal case the capitellum was broken off' and 
the upper posterior angle of the olecranon broken 
(extra-articular) by the fall of a heavy stone. The capitellum. 
injury was compound and the skin so contused that it 
sloughed ; the ensuing suppuration led to later excision of the end of 
the humerus. Recovery with preservation of rotation of the forearm. 
In another the lower two-thirds of the capitellum was broken off, 
but remained attached posteriorly (Fig. 148). The arm had boon 
caught between a tugboat and a float. There was a largo hematoma 
and a small wound of the skin. I exposed the fracture and fas- 
tened the fragment in place with periosteal sutures. Good result. 

1 Hahn: Quoted by Gurlet, loo. cit., p. SOI. 

2 Steinthal : Centralb. f. Chir., 1S9S, p. 17. 




268 



FRACTURES. 



In a third case the line of fracture was nearly parallel to the long axis 
of the humerus, in a frontal plane, and the fragment had been displaced 
upward and had united with the humerus. I removed it. 

In a case similar to this last one Dr. Carleton Flint (oral communica- 
tion) found the fragment united with the humerus in such a way that the 
lower part of its surface of fracture rested against the side of the head 



Fig. 149. 




Fig. 150- 





Fracture of inner rim of trochlea. (Tracing from 
an imperfect skiagram.) 



Fracture oi.capitellum. 

of the radius and had become eburnated. Rotation was preserved ; 
flexion and extension almost entirely lost. Removal of the fragment 
restored motion between the angles of 45° and 165°. 

The local reaction, as evidenced by pain, swelling, and loss of func- 
tion, is comparatively slight or tardy in appearing ; in four of eight 
reported cases the fragment was displaced upward within the capsule 
of the joint, in three (all Kocher's) backward, lying between the head of 
the radius and the olecranon, where it could be easily felt, in one 
(Flint) outward and downward. Kocher removed the fragment in all 
his cases and secured a good result. Lorenz 1 reports 2 cases success- 
fully treated by excision of the fragment, and quotes 2 others (Hahn, 
Steinthal) in which the fragment was displaced upward beyond the 
head of the radius. 



1 Lorenz : Deutsche Zeitschrift fur Chir., vol. 78, p. 531. 



FRACTURES OF THE HUMERUS. 261) 

Fracture of the trochlea alone is very rare. Laugier first called at- 
tention to it in 1853 in a report of a case in which the diagnosis rested 
only on scanty clinical evidence. I have had a case in which a frag- 
ment of the lower part of the inner rim of the trochlea, about three- 
fourths of an inch long, had been broken off and could be easily felt 
beneath the epitrochlea. The displacement was slight, so I did not 
excise the fragment, but simply immobilized the joint. The result was 
good. In another case, Fig. 151 with a larger fragment, the same 
plan was followed with a similar result. 

Diagnosis. 

There is so much in common in these injuries of the lower end of the 
humerus that it is w T ell to summarize the methods of examination and 
the principles of treatment. 

In most cases of injury the diagnosis at first sight rests between frac- 
ture, dislocation, and sprain ; the first two have positive signs by which 
they can be affirmatively recognized, the latter has its own signs, but 
its diagnosis must be confirmed by exclusion of the other injuries. 

If the case is seen early the absence of swelling greatly facilitates 
examination ; if excessive swelling is present it may be diminished by 
vertical suspension of the limb or by the use of the elastic bandage, 
and the fluoroscope or the skiagram may give information that cannot 
be got at the time by palpation. The region in which swelling begins, 
or to which it remains limited, is the one which specially requires close 
examination. 

After the history of the accident has been obtained — usually too 
vague or uncertain to be of much value — and in the absence of indi- 
cations pointing clearly to one or another portion of the bone or one or 
another kind of injury, the surgeon seeks to place the ends of his 
thumb, index-, and middle finger on the two epicondyles and the tip of 
the olecranon in order to determine their relative positions and to note 
if their relations are normal in such attitudes as he can give to the 
joint. This examination, if it can be satisfactorily made, should at 
once determine the presence or absence of a dislocation of the ulna, 
and of the radius if the head of that bone is next found. 

If dislocation has thus been excluded and if the patient is not too 
young, he next seeks the indications given by pain, grasping the elbow 
with one hand and the shaft of the humerus with the other and press- 
ing the two together and then sideways, with thumb and fingers on the 
epicondyles, determining also by the latter movement the presence 
or absence of abnormal mobility of the lower end upon the shaft ; if 
the results suggest supracondyloid fracture confirmation is sought by 
exploration of the condyloid ridge for points of pain and irregularity 
of outline, and the shaft is traced downward to determine its relations 
to the condyles. The condyles are also pressed together to note the 
pain of a fissure running down between them, or each is grasped between 
the thumb and fingers and the effort made to move them on each other. 

The positive sign of fracture of either condyle is its independent 
mobility, recognized by grasping it between the thumb and lingers and 



270 FRACTURES. 

moving it backward and forward. Corroborative evidence, or evidence 
that may be deemed sufficient in absence of independent mobility, is 
pain on point pressure on the condyloid ridge and abnormal abduction 
or adduction of the forearm, adduction in fracture of the external, 
adduction in that of the internal condyle, and pain, especially on^move- 
ment in the opposite direction. 

Fracture of the internal epicondyle is shown by its abnormal mobility. 

The positive evidence in every case is the independent mobility of 
the fragment, usually with crepitus, and only when that is unrecog- 
nizable because of the impossibility of properly grasping the fragment 
should the surgeon rest his diagnosis upon other symptoms. If this 
rule and that of always determining the relative positions of the ends 
of the bone constituting the joint were followed, the disastrous con- 
founding of fractures and dislocations would be much less frequent. 
Anaesthesia is indispensable in many cases for a complete examination. 

Treatment. 

The tendency to displacement except by the unsupported or im- 
properly supported weight of the limb is so slight that if reduction 
can be made a satisfactory result should be obtained in most cases, 
the exceptions being those in which the functions of the joint are dimin- 
ished by obstructive callus or by peri-articular thickening. Consequently 
every effort should be made to effect complete reduction, especially when 
the fracture extends into the joint, even, if necessary, by exposure 
through an incision, and then to prevent its recurrence by so support- 
ing the limb that this cause of displacement may not become operative. 
In the great majority of cases efficient immobilization and protection 
are afforded by moulded anterior and posterior plaster splints, the elbow 
being flexed at a right angle and the limb supported at the wrist by a 
sling. But in the low supracondylar fractures in children this attitude 
exposes to lateral displacement by gravity and consequent marked 
cubitus varus, and should be guarded against as above described. If 
the sling is broader and so placed as snugly to support the limb at the 
elbow, it may easily produce a slighter form of cubitus varus in frac- 
ture of the internal condyle or in the higher supracondyloid fractures, 
by pressing the internal condyle or the inner portion of the lower frag- 
ment respectively upward. 

The stiffness which is found when the splints are removed will ordi- 
narily disappear promptly under natural use. The period can be short- 
ened by systematic daily massage, begun at about the end of the second 
week. Bony anchylosis is extremely rare. 

For the details of special cases which cannot well be summarized the 
reader is referred to the preceding sections, and for fracture of the 
adjoining portions of the radius and ulna, to the following chapter, 



CHAPTER XX. 

FRACTURES OF THE BONES OF THE FOREARM. 

In the Vicinity of the Elbow-joint : Olecranon, coronoid process, head and neck 
of radius — Fractures of the Shaft : Both bones, ulna, radius — In the Vicin- 
ity of the Wrist : Of the radius, Colles's, other than Colles's. 

1. IN THE VICINITY OF THE ELBOW- JOINT. 
A. Fractures of the Olecranon. 

The frequency of fractures of the olecranon has been very differently 
estimated by different writers, Malgaigne placing it among the rarest, 
only nine cases in a total of more than 2300 fractures treated during 
eleven years at the Hotel-Dieu. The table in Chapter I. gives 118 
cases in a total of 14,566 (0.8 per cent.). 

The line of fracture may lie at any point above the base of the 
coronoid process, crossing the bone transversely or obliquely or along 
a V-shaped line corresponding somewhat to the borders of the trian- 
gular subcutaneous surface of the olecranon.*- In rare cases it is 
comminuted, and sometimes is compound. In a very few cases the 
epiphysis has been broken off along the line of the conjugal cartilage. 

The commonest cause by far — 36 out of 45 cases collected by one writer 
— is thought to be a fall upon the elbow. The mechanism, however, is 
apparently not simply that of fracture, by direct violence, the bone is not 
broken solely by a force acting directly upon the end of the apophysis, 
but the contraction of the triceps must play an important part in it. 
Among the reasons for this belief are the usual absence of the signs of 
direct violence upon the surface of the region sufficient to have caused 
the fracture, and the impossibility of producing similar fractures upon 
the cadaver by this means. When the fracture is produced experi- 
mentally by direct violence, by a blow with a blunt object, the bone is 
not broken cleanly and transversely at its narrowest part, as is the case 
in most fractures observed clinically, but it is crushed and split into 
several pieces. The explanation that seems most plausible is that a 
sudden change is effected in the position of the forearm by the fall 
when the muscles are all tense. The man falls with his elbow partly 
bent, and all his muscles rigid with the effort to save himself; his out- 
stretched hand or the back of his forearm encounters some solid object, 
and the flexion of the limb is suddenly and violently increased, while 
the olecranon is held immovable by the triceps. The consequence is 
that the ulna is bent about the elbow, and breaks at the weakest part 
of the olecranon if the violence is received near the elbow, or. perhaps, 
at some part of its much thinner shaft if the violence is received upon 
the hand. 

271 



272 



FRACTURES. 



Occasionally the olecranon has been broken in an attempt to reduce 
an old dislocation or to mobilize a stiff elbow ; and it has been alleged 
that a blow upon the back of the ulna near the elbow can break or 
crack the olecranon from the articular surface outward. 

Muscular action, contraction of the triceps, appears to be an occa- 
sional cause, as in throwing a ball or vigorously pushing with the' elbow 
partly flexed. In such fractures the fragment torn off is small, little 
more than the cortical layer of the summit of the process to which the 
triceps is principally attached ; in other cases the line of fracture lies 
usually at the narrowest part of the process, directly under the centre 
of the sigmoid fossa, that which is called by some the centre, by others 
the base, of the olecranon. 



Fig. 152. 




Fracture of olecranon, x-ray tracing. 
Fig. 153. 




Fracture of olecranon, x-ray tracing. 

Another variety of fracture, partial or complete, and produced from 
within outward, has been spoken of by different writers as theoretically 
possible, but has only recently been observed and described clinically. 
Pingaud l produced it experimentally in the effort to dislocate the ulna 
backward by over-extension (extension beyond the straight line) of the 
forearm. The end of the olecranon is pressed againt the humerus, 
the lateral ligaments resist the movement, and the prolongation of the 
effort results in fracture of the olecranon or, much more commonly, of 
the thinner and weaker shaft of the ulna. Quintin 2 reports three 
cases of incomplete fracture of the olecranon ; the surface articulating 
with the humerus was broken, the dorsal portion was unbroken ; in all 

1 Pingaud: Diet. Encylopedique, art. Coude, pp. 517 and 631. 

2 Quintin : Beitrag zur Lehre von den Bruchen des Olekranon, Bonn, 1881, Abstract in 
Centralblatt fur Chirurgie, 1881, p. 763. 



FRACTURES OF THE BONES OF THE FOREARM. 273 

the swelling was moderate, the pain severe, flexion and extension com- 
plete but slow. In the first case, seen a week after the accident, a small 
prominence could be felt on the side of the olecranon, and behind it 
was a notch ; the upper end could be sprung back a little. In the 
second case a short shallow groove could be felt on the outer side of 
the olecranon, at its base ; and in the third the olecranon could also be 
sprung. Quin tin thinks this fracture is frequently overlooked and 
treated as a simple contusion. The symptoms in the three cases 
described will, perhaps, hardly be considered entirely demonstrative, in 
the absence of corroborative testimony of direct examination, of a 
recent fracture ; and, indeed, it is only by admitting that the injury is 
a common one and has heretofore always been overlooked that its 
occurrence three times during a short period in the experience of one 
observer can seem probable. 

Symptoms. The symptoms of the fracture are pain, swelling, dis- 
placement, and mobility of the upper fragment, sometimes crepitus, 
and loss of power, especially of active extension. 

As the result, apparently, of theoretical considerations, and of what 
has been observed in exceptional cases, the tendency to displacement 
upward of the fragment by the contraction of the triceps has been 
somewhat overstated. This action of the muscle is greatly restricted 
by the lateral aponeurotic attachments and ligaments, and by the exten- 
sion of the insertion of the triceps along the lateral and posterior aspects 
of the olecranon, all of which must be ruptured before the fragments 
can be widely separated and the upper one drawn high up. In a dis- 
cussion in the Societe de Chirurgie which followed the presentation by 
Bardinet of a paper upon this subject, Robert, Richert, and Gosselin 
testified to the usual absence of separation in their experience, and 
similar testimony has since been furnished in abundance. 

If the thick periosteum and tendinous attachments on the sides and 
back of the olecranon are torn, nothing remains to hold the fragments 
together, and separation may be effected either by the contraction of 
the triceps, drawing the upper fragment away from the shaft of the 
bone, or by flexion of the forearm, drawing the bone away from the 
fragment. In either case coaptation is effected by extending, straight- 
ening, the forearm upon the arm, because the triceps cannot draw the 
fragment above the position which it takes in complete extension 
unless the ligaments which bind it to the humerus are torn, and this is 
a complication which apparently happens very rarely. 

In old ununited cases the gradual retraction of the triceps draws 
the fragment upward, but not even in such has it risen above the ole- 
cranon fossa. 

Another displacement, one that is important because of the danger 
that the skin may be broken by the pressure to which it leads, is an 
angular one observed in a few cases when the line of fracture has been 
near the base of the coronoid process, and especially when its direction 
has been obliquely downward and backward and the upper fragment 
has ended in a sharp lower edge or point. 

Coincident dislocation of the radius and ulna forward is occasionally 
seen. (See Chapter XLV., and Plate XV I ['.), 
18 



274 FRACTURES. 

Mobility of the fragment is recognized by grasping it between the 
thumb and finger and moving it laterally, or by flexing the forearm 
gently while the finger is pressed against the groove or crack left by 
the separation when it is slight. If the fragments are brought together 
by extending the forearm or drawing the upper fragment down, crepi- 
tus can be felt. 

If the swelling is sufficient to prevent recognition of these objective 
signs, the fracture may be suspected from the history of the case and 
the loss or marked diminution of the power of active extension. 

Repair. It is very important, with reference both to the treatment 
and prognosis, that the character and extent of the displacement 
should be known. As a rule, union takes place, but it is fibrous, not 
bony ; and the restoration of function depends in a measure upon the 
length of the fibrous band. I say "in a measure," for experience 
has shown in not a few cases that there may be excellent control over 
the limb even with a long fibrous band between the two fragments. 
The disability sometimes observed under the opposing conditions, 
limitation of motion when the band is short, is due to adhesions 
between the fragment and the humerus, or to change in the flexibility 
and length of the capsular bands. The process of repair involves two 
dangers : defective union or failure of union between the fragments, 
and the formation of the intra-articular bands or changes in the artic- 
ular and peri-articular tissues. 

Instances of bony union do exist. Malgaigne figures and describes 
one in his Atlas (Plate XXIV., fig. 2), which, however, differs 
notably from the ordinary fracture, the line having run so obliquely 
as to bring away with the olecranon a lateral half of the coronoid pro- 
cess. Many instances of union with very slight separation, if any, 
and apparently bony, have been reported, but in only a few has the 
character of the union been established by autopsy. Gurlt l describes 
and pictures two : one, a fracture half an inch from the apex of the 
process, united with slight displacement of the fragment upward and 
only a small amount of callus on the outer side ; the line of fracture 

is partly visible upon the surface 
Fig. 154. of section, and complete extension 

of the joint is prevented by an over- 
growth of bone at the apex. The 
other is an oblique fracture (Fig. 
154), and has united so completely 
that the onlv siarn of it is "a shal- 
low groove on the under surface of 

Fracture of olecranon ; bony union. (Gurlt.) the olecranon running obliquely 

backward from the radial to the 
ulnar side. The articular cartilage is lacking in part, and the callus 
consequently visible." Apparently bony union is more probable when 
the fracture is oblique. 

The length of the fibrous band varies within very wide limits. Fig. 
155, taken from Malgaigne, represents a comparatively short band 
and one that presents another peculiarity in that it consists of two 

1 Gurlt : Loc. cit. ; vol. i. p. 41, Fig. 9, and p. 310, Fig. 121. 




PLATE XVII 




Fig. 1. 



Fracture of Olecranon ; Dislocation forward of Radius 
and Remainder of Ulna. 




I 



' 



Fig. 2 — Fracture of Forearm ; Angular Displacement. 



FRACTURES OF THE BONES OF THE FOREARM. 



275 



lateral bands with a central interval or gap. This is by far the most 
common mode of reunion, and although several cases have been 
reported in which the patient appeared to have regained full use of the 



Fig. 155. 




Fracture of the olecranon ; fibrous union. (Malgaigne. 



arm, notwithstanding fibrous union with separation to the extent of 
half an inch more, yet actual deficiency in the power of active exten- 
sion of the forearm is to be regarded as a frequent result of fibrous 
union, and its degree will vary directly with the length of the band. 
The disability may be unnoticed by others, and its consequences may 
be avoided or diminished by care in the use of the arm, by avoidance 
of positions and movements which require the especial action of the 

Fig. 156. 




Ununited fracture of the olecranon, a, the upper fragment ; b, the external condyle. 

triceps, but it exists and can be readily demonstrated. Malgaigne 
describes a case in which the fragment apparently had not reunited 
with the shaft, and yet the patient could use the limb actively, and 
even handle a sword or a foil. On examination it was found, how- 
ever, that the vigor and strength of the arm depended largely upon its 
position, being greatest when the hand was supinated and the arm 
dependent, and disappearing almost entirely when the arm was raised 
above the horizontal line. 

Failure of union, as in the case just mentioned, is not very uncom- 
mon ; the upper fragment may remain freely movable, or it may become 
adherent to the humerus. In a case of the latter condition which came 



276 FRACTURES. 

under my observation thirty-five years after the accident (Fig. 156) 
the forearm could be completely flexed and could be extended to 135 
degrees, the force of extension being very feeble. 

In the majority of cases union takes place with but little separation 
and with full restoration of function, so far at least as power is con- 
cerned, although extension is often incomplete. 

A still more unfortunate result, anchylosis of the joint, has followed 
in a small number of cases. Malgaigne quotes from Camper and 
Trioen an anatomical specimen of bony fusion, and although it is not 
specifically asserted that the union was between the ulna and the 
humerus, this seems probable from the context. Thierry, according 
to Pingaud, reported two cases of articular rigidity that had lasted, the 
one for six months, the other for a year, in spite of the most persistent 
efforts to overcome it. I have seen a case in which the joint was stiff 
in full extension after wiring of the fragments, although the operation- 
wound had healed without suppuration. 

The course of the fracture is ordinarily very simple aud uncompli- 
cated ; the swelling subsides promptly and union takes place in from 
three to four weeks. 

Treatment. Discussion concerning the proper treatment of fracture 
of the olecranon has turned mainly upon the position to be given to 
the limb, some favoring the extended position in order to secure closer 
union of the ligaments, others recommending flexion, either because 
they did not fear separation of the fragments and sought the position 
that could be kept with the least discomfort, or because they feared 
anchylosis and wished to have the limb in the most favorable position 
if it should occur. It is evident from the facts that have been already 
stated that neither the first nor the third reason is sufficient to establish 
a rule of practice to be followed in all cases. The probability of the 
occurrence of anchylosis after simple fracture is very small, so small 
that it ought not to be w r eighed against that of non-union when the 
fragments are separated rather widely. On the other hand, the sepa- 
ration at first is so slight in many cases and the extended position so 
unnecessary to overcome it that if partial flexion is more comfortable 
to the patient, if it makes the restraint less irksome, it should not be 
denied him. Furthermore, there appears to be danger of two displace- 
ments in complete extension : if the fracture is at or near the base of 
the process the ulna can be readily dislocated forward ; and secondly, 
effusion into the joint or swelling of the capsule may prevent the tip of 
the olecranon from sinking into the olecranon fossa to the usual depth, 
and under such circumstances complete extension of the forearm would 
cause a tilting, an angular displacement of this fragment. This latter 
point has been made by several writers upon theoretical grounds alone, 
but, although it seems plausible, no confirmatory observation has been 
made, so far as I know. 

The aim of treatment should be to secure bony union if possible, and, 
failing that, close fibrous union, and this consideration will regulate the 
position to be given to the arm. If there is wide separation which 
increases as the elbow is flexed, if the fragments cannot be brought 
well together except by extending the forearm, that position must 



FRACTURES OF THE BONES OF THE FOREARM. 277 

be taken and kept until consolidation is well advanced. If, on 
the other hand, the separation is slight and the upper fragment 
follows the movements of the lower, if they can be easily brought to- 
gether and kept so by moderate traction upon the upper one, the 
patient may be safely allowed the comfort of the partly flexed posi- 
tion. 

Apparently it is not often necessary to take especial measures to draw 
the upper fragment down to the lower one, and even when there is con- 
siderable separation between them in the flexed position it is usually 
sufficient simply to extend the elbow. Some methods of treatment, 
however, have been designed with the especial intention of drawing 
the fragment down, and it has been sought to accomplish this by figure- 
of-eight bandages passing above and below the fragment and crossing in 
front of the elbow, or by circular bands about the arm drawn together 
by longitudinal ones. In others, strips of adhesive plaster have been 
applied to the skin above the olecranon, drawn down snugly, and fast- 
ened to the skin of the forearm or to the splints ; sometimes the plaster 
is cut in the form of a U, the olecranon lying in the angle and the two 
sides passing along the forearm. 

Metal hooks similar to those used in fracture of the patella have 
also been used here successfully, although not frequently. I do not 
know when or by whom they were first employed, but Busch recom- 
mended them in 1864, and Pingaud 1 speaks of the use of a similar 
method a a very long time ago" by Prof. Rigaud, of Strasburg. It 
is sufficient that the hook should have but a single point at the upper 
end, and at the other end should be made fast to a gypsum bandage 
covering the arm and forearm and provided with a large fenestra 
behind the elbow. 

The best splint is an anterior one made fast to the limb by a roller 
bandage or a fenestrated gypsum bandage. It is not worth while, I 
think, to try to force the upper fragment down by turns of a roller 
bandage, because this can be done much more effectively when necessary 
by adhesive plaster or hooks. In short, the treatment to be recom- 
mended is as follows : If the separation is slight and is not increased 
by the flexed position it is only necessary to immobilize the limb with 
the forearm slightly flexed, about midway between complete extension 
and flexion at a right angle, and for this purpose an anterior splint of 
wood or of plaster of Paris is sufficient and convenient. If the frag- 
ment shows any tendency to be drawn up it should be secured with 
adhesive plaster. If, on the other hand, there is notable separation, 
and if the separation is increased by flexion of the forearm, the exten- 
sion should be complete enough to bring the fragments together, and it 
should be aided by adhesive plaster or hooks. The fenestrated gypsum 
bandage seems to be the one best fitted for this purpose, and the fenes- 
tra should be large enough and so placed as to permit inspection of the 
seat of fracture. If Malgaigne's hooks are used in connection with it 
one hook or pair of hooks should be forced through the tendon ot^ the 
triceps down to the bone, and the other pair fixed to the gypsum 
bandage below the fenestra. In one of three cases recorded by Quin- 
1 Pingaud : Diet. Encyclope'dique, art. Coude, j>. 639 (1878), 



278 FRACTURES. 

tin, 1 the hooks remained in place four weeks without causing any 
inflam ma tor v symptoms. 

If the patient is rheumatic, or if the reaction has been severe and 
prolonged and anchylosis is feared, it is well to change the degree of 
flexion slightly from.time to time after the pain and inflammation have 
disappeared ; and if the tendency to separation is slight this change of 
position may be begun quite early. It must be done very gently and 
cautiously, and the upper fragment must be supported by the finger in 
order that the adhesions may not be ruptured. In a case reported by 
Pingaud, 2 the callus was broken by this attempt at passive motion ; 
and as the surgeon did not dare to immobilize the joint again for three 
or four weeks he applied a plaster bandage to the forearm, and used it 
as the support for a pair of Malgaigne's hooks by which he was enabled 
to keep the fragment perfectly in place, and at the same time to move 
the elbow as much as he wished. 

Lauenstein 3 used in one case a method of preliminary treatment 
recommended by Volkmann in fracture of the patella : aspiration of 
the joint to remove the blood and synovia. There was separation to 
the extent of half an inch and the joint w T as distended ; he removed 50 
c.c. (about 1J ounces), dressed the limb in the extended position upon 
an anterior splint, and drew down the fragment by means of longitu- 
dinal strips of adhesive plaster renewed about once a week. Recovery 
followed without displacement and with full use of the joint. Another 
case is reported in the Centralblatt fur Chirurgie, 1885, p. 570. 

In a few cases the fragments have been wired together ; when resort 
to such a measure was deemed necessary I have preferred sutures 
through the fibro-periosteum adjoining the fracture, or a suture through 
the tendon of the triceps and a hole drilled transversely in the ulna 
below the fracture. 

In a few cases of fibrous union with much separation and consequent 
disability operative measures, according to some of the various plans 
mentioned in Chapter VIII., have been undertaken to obtain closer 
union ; and some surgeons have obtained good results by excising the 
fibrous band and wiring the fragments together. 

B. Fractures of the Coronoid Process. 4 

This fracture, the frequency of w T hich has been much disputed, is 
unquestionably very rare except as a complication of dislocation of the 
ulna backward. 

So far as can be inferred from the few detailed descriptions of speci- 
mens the line of fracture crosses the process transversely or somewhat 

1 Quintin: Centralblatt fur Chirurgie, 1881, p. 764. 

2 Pingaud : Gazette Hebdomadaire, May 21, 1875. 

3 Lauenstein : Ceutralblatt fur Chirurgie, 1881, p. 172. 

4 The references to the specimens in the first edition are: Cooper, Fractures and Dis- 
locations, p. 411 ; S. Cooper and Gibson, quoted by Hamilton ; Velpeau, Annales de la 
Chir., 1843, vol. ix. p. 98; Berard, Diet, de Med., en 30 vols., art. Coude, p. 228; Gurlt, 
vol. i. p. 41 ; Bryant's Surg., 3d Am. ed., vol. i. p. 837; two in Holmes's System, Am. ed., 
vol. i. pp. 859, 860; Annandale, Medical Times and Gazette, 1875, vol. i. p. 576, and 
Edinburgh Medical Journal, February, 1885, p. 681. For a personal case seethe following 
section, Fractures of the Head and Neck of the Eadius. 



FRACTURES OF THE BONES OF THE FOREARM. 



279 



obliquely at about one-fourth of an inch below its apex, and may 
reunite with a close bony union or by a fibrous band. When the 
union is close and bony there may be a somewhat exuberant callus 
upon the anterior aspect of the process, due probably to the stripping 
up of the periosteum or tendon. 

The mechanism in the great majority of cases is by indirect violence 
exerted in such a way as to cause dislocation of the joint backward and 
to break off the point of the process as it is forced past the trochlea, 



Fig. 157. 




Fracture of the coronoid process of the right ulna. 
United with exuberant callus on the anterior surface, 
line of fracture still visible on the articular surface. 
a, a small fragment broken from the articular border 
of the olecranon and reunited. (Gurlt.) 



Fig. 158. 




Fracture of the coronoid process and 
the head of the radius. (Bryant.) 



and in such cases there is also sometimes fracture of the anterior por- 
tion of the head of the radius. In one case mentioned by Lotzbeck l 
the process appeared to have been broken off by direct violence ; a 
soldier was struck in the elbow by a piece of a shell which caused a 
severe contusion but no open wound. Two months afterward the coro- 
noid process could be felt as a movable body, and by pressing it down 
it could be made to rub against the ulna with a creaking sound. Acu- 
puncture proved the supposed fragment to be a hard solid body. In 
another case, that of a boy fourteen years old, the process was broken off 
by extreme flexion of the elbow. A somewhat similar personal expe- 
rience may be mentioned as corroborative of this mechanism to a cer- 
tain extent. I excised an elbow for suppurative disease of the joint, 
using Oilier' s postero-lateral incision. In order to facilitate the clean- 
ing of the external condyle, and before the olecranon had been touched, 
I asked the assistant to flex the elbow ; he did so with some force, and 
felt something snap. About half an inch of the coronoid process was 
found to have been broken off. It seemed, however, to be unusually 
long and prominent, possibly by ossification of the attached capsule in 
consequence of the prolonged inflammation. 

As regards experiment upon the cadaver we have the assertion ot y 
Malgaigne, 2 that in producing dislocations backward he broke off the 
end of the coronoid process quite frequently, and the more detailed 
results of Lotzbeck who fixed the elbow in a slightly flexed position by 
means of a gypsum bandage and then by striking upon the palm of 
the hand broke the coronoid process five times in ten attempts. 



1 Lotzbeck : Schmidt's Jahrbuch, 1S66, vol. exxix. p. 134. 

2 Malgaigne : Luxations, p. ('34. 



280 FBACTUBES. 

Schwenk (ZUblattf. Chir., 1908, p. 976) reports a similar case without 
dislocation, confirmed by the .v-rays. 

The mechanism of this production and the anatomical relations of 
the process explain the union with slight displacement shown in some 
of the specimens and the difficulty of diagnosis during life. The ten- 
don of the brachialis anticus is inserted not upon the top of the process 
but upon its anterior aspect and base, and the articular capsule is 
attached all along its edge. When it is broken off by being forced 
backward against the trochlea its connection with the ulna is preserved 
in front by the tough attachments of the tendon, and therefore instead 
of being displaced bodily along the anterior aspect of the bone it is 
probably only tilted forward. Its vitality is assured in any case by 
its connection with the capsule, and when the dislocation is reduced 
the fragment is held exactly in place by the tendon of the brachialis 
anticus in front and the humerus behind. 

The symptoms and the means of diagnosis, in view of the uncer- 
tainty of the diagnosis in the supposed cases, cannot be positively 
described ; those which have been deemed sufficient are : dislocation 
backward, easy reduction, great tendency to recurrence, possibly crepi- 
tus, and the presence of a hard movable body in front of the elbow in 
the line of the tendon of the brachialis anticus. In a personal case 
the supposed fragment could be readily grasped between the thumb 
and finger and moved freely to and fro. 

Treatment. The treatment consists in immobilization of the joint 
flexed to a right angle or beyond. The degree of flexion and the com- 
pleteness of the immobilization may vary with the tendency to dis- 
placement. If the latter is great, experience has shown that it is best 
opposed by increasing the flexion ; and, of course, complete immobil- 
ization gives additional security. The immobilization should be main- 
tained as long as the tendency to dislocation exists ; when that ceases 
the splint becomes unnecessary, and the only indication then is to main- 
tain sufficient flexion to favor prompt and close union. 

C. Fractures of the Head of the Radius. 

Our knowledge of this variety of fracture is drawn from about a 
score of specimens, old or recent, and a constantly increasing number 
of clinical cases supported by skiagrams. It has recently been studied 
by Thomas l in a paper admirable alike for its thoroughness of research 
and its soberness of judgment. Apparently the injury occurs quite 
frequently ; Thomas collected 48 cases and found evidence of 55 others 
in skiagrams taken in Philadelphia. The line of fracture may sepa- 
rate a small portion of the head, about one-third, or a much larger 
portion passing down through the neck, or may split the head into two 
or more pieces and separate all of them from the shaft. Usually the 
fragments retain connection with the periosteum of the neck. 

Cause. The cause may be a blow upon the head of the bone (Stim- 
son, Cheyne, Delorme), or a wrench of the forearm, probably forced 
abduction (Stimson), or a fall on the palm, or the injury may occur as 
1 Thomas : Univ. of Perm. Med. Bull., vol. 18, p. 184. 



FRACTURES OF THE BONES OF THE FOREARM. 



281 



an incident of a backward dislocation of both bones of the forearm or 
of the head of the radius. The form of the fracture varies with the 
cause : fracture of a small portion of the head is the form seen in dis- 
location and in fracture by direct violence ; the more extensive frac- 
tures — splitting of the head and complete separation from the shaft — 
are seen when the limb has been violently wrenched. I have seen five 
of the former — four in dislocation and one by direct violence — and five 
of the latter verified by arthrotomy and four'probable cases observed 
clinically. 

In the cases accompanying dislocation a small piece, comprising 
about one-third of the periphery, is broken off, probably the portion 
that is anterior when the head is forced past the capitellum. I have 
found it lying, after reduction of the dislocation, beneath the external 
epicondyle between the radius and the olecranon, and the portion of 
the head of the radius accessible to palpation did not comprise the gap 
left by the fracture. In one case the fragment had been displaced 
downward along the neck and had become attached, limiting rotation ; 
I cut it away and covered the raw surfaces with silver foil, getting a 
good functional result. 

In a case of fracture by direct violence (kick by a horse) Cheyne 
found the fragment in the same place and removed it, as he did also in 
another supposed to be by direct violence ; in another Delorme recog- 
nized abnormal mobility of the'undisplaced fragment and treated it by 
immobilization, obtaining complete restoration of function. In mine 
the patient did not come under observation until after suppuration of 
the joint had occurred ; resection was done. 



Fig. 159. 







A B 

Fracture of head and neck of radius, a, first case : b, second case : c, third case ; the portion 
corresponding to the gap was crushed. 

My five certain cases of fracture by violence acting through the 
forearm resemble one another closely. In each the cause was a fall 
from a height, the arm being caught under the body. I imagine that 
the immediate cause was violent abduction of the forearm. Fig. 159 
shows the lines of fracture. In the first, one of the two smaller frag- 
ments was displaced outward and backward, and a primary excision of 
the head and neck was done, with a good functional result. It was 
thought that the coronoid process also was broken. In the second 
there w T as no recognizable displacement at first, and I was not entirely 
certain of the character of the injury ; after immobilization for four 
weeks the functional result seemed so likely to be bad that I opened 
the joint and removed the head and neck, finding the larger fragment 



282 FRACTURES. 

displaced angularly outward aud backward aud reunited with the .shaft. 
In the third case there were two large pieces and a crush of the inter- 
mediate portion, also fracture of the coronoid process and slight dis- 
placement backward of the ulna. I saw the patient a month after the 
accident and removed the head of the radius. The cases are .reported 
in detail in the references given above. In the fourth case the head 
and neck were split and broken off, and in the fifth the fragment com- 
prising about one-third of the head, antero-external, was detached and 
displaced downward and inward. In one case observed clinically 
(details in first edition) reunion followed, with a good functional result, 
notwithstanding a notable enlargement of the upper end of the radius ; 
in the other rotation of the forearm was lost. I haye also had a case 
in which the head of the radius was broken by a pistol-bullet entering 
from the outer side and above. I excised the head, and the functional 
result was good. 

Two of Mutter's specimens and Helferich's show a small portion of 
the head broken off and reunited with displacement. In Pinner's the 
small fragment was eburnated but not reunited, and in Delorme's the 
fragment reunited with conseryation of function. 

These cases show that union is possible, even probable, after fracture 
of the neck or of the head ; in my case in which suppuration followed 
the patient was a delicate strumous lad in whom any serious joint lesion 
would have been likely to have that result. 

Diagnosis. The diagnosis after fracture of a small portion accom- 
panying a dislocation or by direct violence is easy if the fragment is 
displaced to the position beside the olecranon which it has occupied in 
most of the reported cases, for it can then be readily palpated. Its 
removal is easy, and its loss appears to entail no disability. The loss 
of rotation obseryed in one case after removal was probably due to 
adhesions between the surface of fracture and the capsule. 

In the cases of more extensive breaking the diagnosis is easy if there 
is enough displacement of the head to be recognized by palpation and 
if its separation from the shaft is shown by its failure to share in rota- 
tory movements of the forearm. In my second case the head rotated 
with the shaft, and the only sign pointing to its fracture Avas an occa- 
sional click perceived during rotation of the forearm ; there was also 
marked abnormal lateral mobility, especially adduction of the forearm, 
and sharp pain on abduction. If it cannot be felt, the diagnosis must 
be made by local tenderness on pressure, but probably the a-rays are 
needed for a positive recognition. 

The proper treatment of this condition is not so clear ; one of my 
cases regained good use of the joint without operation ; another did 
the same after a primary excision ; the others had all lost more or less 
rotation when first seen some weeks after the accident, and some of them 
much of flexion and extension ; the removal of the fragment or of the 
entire head improved the condition. The results recently obtained by 
massage and immobilization in cases in which an early diagnosis was 
made are encouraging, but I doubt if small completely detached 
portions of the head should be left in ; their reunion is not to be 
expected and their presence is always a danger. Of 18 cases of 



PLATE XV 11 




Fig. 1.— Fracture of Head of the Radius. 




Fig. 2 — Fracture of Neck of the Radius. 




FRACTURES OF THE BONES OF TIFF FOREARM. 283 

Thomas's collection in which the result is known there was good union 
without deformity in 3, with deformity in 5, non-union in 8, 1 bony 
and 1 fibrous ankylosis, and 2 with greatly impaired function. 

D. Fractures of the Neck of the Radius. 

This injury appears to be much less frequent than fracture of the 
head, although Mouchet 1 saw 11 cases in the course of two or three 
vears, all in children under thirteen years of age. The known speci- 
mens are one of Mutter's, united with displacement, 
one each removed by Annandale, Douglas, Mouchet, Fig. 160. 

and myself, and one found by Moullin on amputa- 
tion. Moullin's 2 was a separation of the epiphysis. 
In several other cases the line of fracture has been 
shown by the *T-rays (Plate XVIII. ). Mouchet's 
is shown in Fig. 160. 

Mutter's specimen of fracture of the neck alone 
is without history of the cause or symptoms ; in 
Annandale's the patient, a man forty years old, 
received a severe jar of the elbow by striking his 
wrist against his knee while shovelling. He did „ 

P , , , ., . it, a n, Fracture of neck of ra- 

not seek treatment until six weeks later. Alter a dius. (mouchet.) 
month's immobilization the joint was opened ; the 
head was found loose and the neck atrophied. 

Dr. Richard Douglas, of Nashville, reported to me a case of fracture 
of the neck by a blow on the inner side of the forearm, verified by a 
late arthrotomy. A prominent feature was marked flattening of the 
inner side of the elbow, with extensive ecchymosis, which I attributed 
to avulsion of the flexor museles in forced abduction of the forearm. 

In November, 1902, I saw at the Hudson Street Hospital a man 
whose right elbow had been dislocated (and reduced) two days previ- 
ously. The flexed forearm could be moved slightly backward and 
forward upon the arm, there was a gap below the capitellum, and the 
head of the radius could be plainly felt in the flexure of the joint. I 
exposed the joint by an external incision and removed the head of the 
radius, which had been broken off by a fracture through the neck. The 
coronoid was broken at its base. 

Bolton, at the New York Hospital in 1907, found the head inclined 
outward, forced it back into place, and got a good result. 

The line is transverse or somewhat oblique, and the proximal frag- 
ment usually has an angular displacement, the angle opening outward 
and backward. The mode of production has varied greatly — a fall on 
the hand, a blow on either side of the forearm, a wrench of the forearm, 
a crush of the elbow in a machine. Definite diagnostic features are 
not known beyond pain at the site of fracture and especially on 
attempting supination (Mouchet). Here, too, the .r-rays will probably 
be the final arbiter in doubtful cases. 

1 Mouchet : Revue de Chir., vol. 21, p. 596. 

2 Moullin: Trans. Path. Soc. London, vol. 39, p. 242. 



284 FRACTURES, 

Mouchet\s 9 fresh cases recovered with good function after treat- 
ment by massage and mobilization. Adults have not done so well, 
and late excision may be required to improve function. 

2. FRACTURES OF THE SHAFT. 

A. Fractures of the Shafts of Both Bones. 

The relative frequency of fracture of both bones may be seen by 
reference to the table in Chapter I. It occurs rarely in the upper third 
and with about equal frequency in the middle and lower thirds. Usu- 
ally the radius is broken nearer the elbow than the ulna. 

Cause. The cause may be direct or indirect violence or muscular 
action, a fall upon the hand, or the bending of the forearm across some 
object, or by a transverse blow. 

Only a few instances of fracture by muscular action have been 
recorded, and even in those there was a contributing external force, 
such as shovelling or rising upon the hand in bed. 

Partial or incomplete fractures — " green-stick fractures" — are, 
according to Malgaigne, more common in the forearm than elsewhere, 
and are usually due to a fall upon the hand. 

Displacements. The displacements are of the usual kinds : overrid- 
ing in oblique fractures, lateral with or without overriding in the 
transverse fractures, and angular displacement of one or both bones in 
both forms. Rotatory displacement of the radius alone, especially 
when it is broken above the insertion of the pronator teres, was first 
pointed out apparently by Lonsdale. He suggested that the upper 
fragment might be strongly supinated by the biceps, while the lower 
fragment was kept in the usual semi-prone position, and he thought 
this might be a cause of the inability to supinate the hand completely 
sometimes observed after fracture. Flower and Hulke l say they have 
found proof of the correctness of this conjecture in the examination 
of numerous specimens of united fracture of the radius, " in a great 
number of which the lower fragment was much less supinated than 
the upper," and Agnew says there are similar specimens in the collec- 
tions of the College of Physicians and the University of Pennsylva- 
nia. Mr. Callender 2 examined eighteen specimens of united fracture 
of the shaft of the radius in the London museums, and found in fifteen 
of them rotatory displacement averaging 36 degrees, the extremes 
being 6 degrees and 64 degrees. The displacement in every case was 
that pointed out by Lonsdale, supination of the upper fragment. The 
agency of this rotatory displacement — supination of the upper frag- 
ment — in preventing full supination of the lower segment after heal- 
ing appears much more likely to be efficient in fractures below the 
insertion of the pronator radii teres, for that muscle is the main oppo- 
nent of the exaggerated supination of the upper fragment which would 
then be necessary to the full supination of the lower. 

In angular displacement one bone may be bent while the other 
remains nearly straight, possibly with overriding, or the fragments of 

1 Hulke : Holmes's System of Surgery, Am. ed., vol. i. p. 860. 

2 Callender : St. Bartholomew's Hospital Reports, vol. i., 1865, p. 297. 



FRACTURES OF THE BONES OF THE FOREARM. 285 

both bones may be inclined in the same direction, forward, backward, 
or to either side, or there may be lateral inclination in opposite direc- 
tions, each bone being inclined toward the other ; and if the fractures 
are at the same level the four ends may thus be brought into contact, 
and the possibility created of a union that will abolish the power of 
rotation of the limb. Such faulty union of the two bones is, however, 
very rare. Overriding of the fragments has been observed to a dis- 
tance of more than three inches (eight centimetres). 

Symptoms. The symptoms are the usual ones of fracture : pain, 
deformity, abnormal mobility, crepitus, and loss of power. 

The course is usually simple and the prognosis favorable, but both 
may be gravely modified by laceration or bruising of the soft parts or 
by the occurrence of acute inflammatory reaction or of gangrene, and 
in addition the prognosis may be made unfavorable by an irreducible 
displacement or comminution or loss of substance of one of the bones. 
Displacement affects the prognosis when it increases the chances that 
union may take place between the two bones, and comminution or loss 
of substance by favoring the occurrence of pseudarthrosis. 

In simple cases without marked displacement or complication com- 
plete union may be expected in a month, but in no other limb do 
inflammatory complications and gangrene occur so frequently, even 
under prudent treatment. The gangrene may be limited to points 
where the splints have made pressure or to portions of the hand and 
fingers, but it is very likely to involve the entire member if it is over- 
looked at the beginning or not effectively combated. Diffuse phleg- 
monous inflammation of the forearm may follow severe bruising of the 
soft parts or may even take its rise in the fracture. Its importance 
lies in the danger to the life and limb which follows the burrowing of 
the pus, the opening which it necessitates, and the matting together 
of the tendons and their sheaths. 

Ischsemic contraction of the muscles (p. 70) is of especial import- 
ance because of its marked interference with the usefulness of the hand. 

The cause of gangrene in many cases and of ischemic contraction 
has been pressure exerted by splints or bandages, and the necessity 
for caution and watchfulness to avoid this accident cannot be urged 
too strongly. The practice of applying a roller bandage to the limb 
under the splints is extremely dangerous, and so also is the use of 
splints of soft material, pasteboard and the like, which take the shape 
of the limb and are fastened to it with a roller bandage. There is the 
same compression, the same chance of strangulation in this case as 
when the roller is applied directly to the skin. It is not safe to depend 
upon the sensations of the patient, upon pain, to give warning of 
threatening strangulation ; cases, in both old and young, have been 
reported in which total gangrene of the distal portion of the limb has 
occurred without attracting the attention of the patient or his attend- 
ants by any symptoms except the final change in the color of the 
exposed fingers. 

The persistence of angular displacement of both bones, or, to a 
less degree, of the radius alone, affects the prognosis by its inter- 
ference with rotation. In rotation only the radius moves, and its 



286 



FRACTURES. 



movement is about an axis running from its upper end to the lower 
end of the ulna, so that in full pronation the radius crosses the ulna 
obliquely, and in supination is parallel to it and at its maximum dis- 
tance from it at the centre. If now the bones are bent, say in the 
middle third, the radius of rotation of the radius at the apex of the 
angle is correspondingly increased, and this angle must, therefore, 
move to a greater distance from the ulna than normal in supination ; 
such a movement is prevented by the interosseous membrane, and rota- 
tion is correspondingly diminished. This is the most frequent cause 
of diminution or loss of rotation after fracture. The marked dis- 



Fig. 161. 



Fig. 162. 





Fracture of the forearm, angular displacement, 
and union between the bones. 



Fracture of the forearm, with formation 
of a lateral joint. 



placement of the radius in the case represented in Plate XX V fig. 1, 
caused the loss of only half of the rotation. 

The possibility of union between the bones as well as the fragments, 
though rare, should also be borne in mind. Its occurrence is more 
likely when the natural interval between them is destroyed or dimin- 
ished by displacement, but this approximation is not essential. Excess- 
ive formation of callus, in consequence of laceration of the intermediate 
tissues and irritation, especially of the interosseous membrane, is suffi- 
cient in itself to produce this result so destructive of the usefulness of 
the limb. The occurrence is favored also by correspondence in the 
position of the fractures, for the fragments are more likely to fall into 
abnormal contact with each other, and the granulations which form the 
callus about each fracture may easily unite if each spreads over only 
half the intermediate space (Fig. 161). It has occasionally happened 



PLATE XIX 




Fig. 1.— Fracture of Humerus by Small B 



ullet. 




Fig. 2 — Fracture of Forearm. 



FRACTURES OF THE BONES OF THE FOREARM. 287 

that the two calluses have come into contact and formed a lateral joint 
(Fig. 162), instead of uniting. Slight inclination of the hand to one 
side or the other is a not infrequent result and may be due to the posi- 
tion of the sling in which the arm is supported ; thus, if the weight of 
the arm is borne upon the sling at or above the point of fracture the 
unsupported hand drops downward and the lower fragment deviates 
toward the ulnar side, as in the figures ; while if the sling passes under 
the hand or wrist and leaves the forearm unsupported the latter sinks 
down between the wrist and elbow and the lower fragment deviates in 
the opposite direction toward the radial side. 

Fig. 163. 





' " C - : ^'^Si 


IL^B 










H§L 


■L^ 


¥■ - .ftS 



Fracture of the forearm ; union with angular displacement. No union between the two bones, 

Delay or failure of union of either or both bones is not very uncom- 
mon, especially of the radius, and cases are reported in which the union 
of one of the bones has been delayed four or five months, and has then 
taken place without operative aid. 

Treatment. Reduction must be effected, when necessary, by exten- 
sion and counter-extension aided by cautious pressure upon the bones 
near the seat of fracture. The importance of reduction is exception- 
ally great, because of the special function of rotation of the forearm 
which may be so easily destroyed by displacement or failure of union. 
I have once or twice found it necessary to cut down upon the fracture 
because I could not otherwise correct the displacement, the fragments 
being so placed after oblique fracture that the surfaces of fracture were 
separated from each other by the entire thickness of the bone and the 
fragments were in contact only by surfaces covered with periosteum. 
Overriding is to be overcome by traction ; the forearm and fingers are 
flexed, counter-extension is made by an assistant who grasps the arm 
close above the elbow, and traction by the surgeon himself or another 
assistant grasping the hand. If there is angular displacement the 
traction should be first made in the direction of the lower fragment, 
and when this is thought to be sufficient, and while it is still main- 
tained, the lower segment of the limb is brought into line with the 
upper one, the latter being steadied by the hand oii the surgeon or pivs>- 



288 FRACTURES. 

lire being made upon the projecting angle with the thumbs. This 
pressure may be safely made if the angle is directed forward or back- 
ward, but it must be used with great caution when the angle is lateral, 
for there is danger that it may force the bone upon which it is made 
too near its fellow, and that when the manoeuvre is completed the posi- 
tion of the fragments may resemble that of the arms of an X, each pair 
being displaced angularly toward the other. To avoid this result the 
hand should be supinated while the reduction is making, because in 
this position the interval between the bones at the centre of the limb is 
greatest and most accessible, and the surgeon should seek to force or 
keep the fragments apart by pressing his thumbs in between them in 
front and his fingers behind. 

The position in which the forearm is usually kept during treatment 
is that which is midway between pronation and supination. It is the 
one which the limb naturally assumes when it is suspended beside the 
body with the elbow bent at a right angle and is the one which is 
borne with the least fatigue and discomfort. But while this position 
meets the indications sufficiently in the simple and, indeed, in most 
cases, it was long since recognized by some surgeons that the bones of 
the forearm are normally separated most widely from each other at the 
centre when the limb is supinated, and that consequently this position 
is the one in which the arm should be kept whenever there appears to 
be danger of the bones uniting with each other. According to Mal- 
gaigne, fractures of the forearm were treated in the supine position by 
the contemporaries of Hippocrates, but the practice was condemned by 
that writer ; it was reinvented by Pare, and abandoned by him when he 
learned that Hippocrates had disapproved of it, a yielding to authority 
that seems to have been unusual with that vigorous-minded surgeon, 
and again reinvented by Malgaigne, who afterward learned that 
Lonsdale had preceded him by a few years. Lonsdale l recom- 
mended the position for a reason mentioned above, the difference 
between the degree of supination of the upper fragment of the radius 
and that of its lower fragment ; Malgaigne recommended it because 
of the greater distance between the centres of the bones when they 
are in this position. 

The difficulty which Lonsdale sought to avoid, supination of the 
upper fragment, appears not to have much importance when the frac- 
ture of the radius is above the insertion of the pronator radii teres and 
to be rare when it is below it ; that which Malgaigne had in mind — 
possible union of the two bones— is rare even when the two bones are 
broken at the same level. The principal faults to be avoided are angu- 
lar displacement and overriding, and so far as these are concerned the 
attitude of pronation or supination seems to be indifferent. The objec- 
tion to the attitude of supination is its greater constraint and incon- 
venience ; if the attitude is desirable the discomfort can be avoided by 
confinement to bed with the arm abducted and the elbow flexed at a 
right angle, in which position the forearm rests easily in full supination. 

A common method of treatment is to fix the limb between two light 

1 Lonsdale : London Medical Gazette, 1832, vol. ix. p. 910. 



FRACTURES OF THE BONES OF THE FOREARM. 289 

wooden splints broad enough to overlap it slightly when applied to the 
palmar and dorsal surfaces. The palmar splint should extend from the 
fold of the elbow to the roots of the fingers, the dorsal one should be 
shorter and not reach beyond the wrist. Each splint should be padded 
with cotton, and patients usually find it agreeable to have the end 
corresponding to the palm of the hand very thickly padded, or a small 




Moulded plaster splint for fracture of forearm. 

roll of bandage fastened obliquely to it so that the fingers can close 
easily over it. 

In simple cases uncomplicated by threatening displacement, the 
splints are applied to the semi-pronated limb and fastened by two 
strips of adhesive plaster wrapped about them, one near the elbow, the 
other at the wrist, the hand is made fast to the palmar splint by a few 
turns of a bandage, and the limb is placed in a sling that supports both 
the elbow and hand. 

The limb should be frequently inspected at first in order to guard 
against excessive pressure either by bandages too tightly applied at first, 
or made too tight by the swelling of the parts, and the splints should be 

removed in the second week to detect and remed v any new displacement. 

19 • 



290 FRACTURES. 

A roller bandage should not be applied to the limb under the splints ; 
it exposes to displacement by pressing the bones toward each other, 
and to gangrene or ischemic contraction by constriction. The com- 
plete plaster-of-Paris dressing is objectionable for the same reasons 
during the first few days, but it or moulded plaster splints including 
the lower portion of the arm may be used after the first week if care 
is taken not to make lateral pressure. 

Anterior and posterior splints immobilize the limb sufficiently to 
meet every indication except that of opposing the tonicity of the mus- 
cles and the occurrence of overriding. When the lines of fracture are 
transverse or toothed the bones themselves afford sufficient protection, 
and in any case flexion of the elbow relaxes many of the muscles and 
diminishes the risk, which, moreover, is not a great one. 

A moulded plaster-of-Paris splint dressing, much used at the Hudson 
Street Hospital, especially in the young, is shown in Fig. 164. As it 
extends above the elbow it efficiently opposes shortening if traction is 
maintained while the plaster hardens. 

In compound fractures great caution should be used in removing 
fragments or excising portions of bone, lest failure of union should 
follow. If the extent and position of the wound are such that efficient 
splints cannot be used at first, the patient should be kept in bed with 
the arm abducted and the elbow flexed, and traction, elastic or by 
weight, made by means of adhesive plaster attached to the hand and 
wrist. Counter-extension can be made from the lower part of the arm 
by a broad bandage, the limb being meanwhile supported upon cushions 
or suspended, and preferably steadied by a splint placed outside the 
dressings of the wound. 

B. Fracture of the Shaft of the Ulna. 

Fractures of the shaft of the ulna alone are almost invariably the 
result of direct violence, of a blow received upon the arm while it is 
raised to protect the head, or of a fall upon the ulnar side of the fore- 
arm. 

Displacement. Displacement may be entirely absent, and when pres- 
ent may be in any direction. Its extent and direction seem to depend 
almost entirely upon the fracturing force. Most recent writers, follow- 
ing the example of Pouteau, 1 have alleged that the broad articulation 
of the ulna with the humerus prevented lateral displacement of the 
upper fragment, and that the lower fragment was therefore the only 
one that could be displaced toward the radius. Even if the articula- 
tion was absolutely free from lateral mobility, the inference that has 
been thus drawn would not be correct, because the radius can be moved 
toward the ulna after fracture of the latter and thus the exact equivalent 
of the displacement of the ulna toward the radius produced. The only 
muscle which acts directly upon the lower fragment is the pronator 
quadratus, the tendency of which is to draw it toward the radius. 

Symptoms. The symptoms may be limited to pain and swelling at 
the seat of fracture, and if their significance should be rendered obscure 
by the history and the effect upon the soft parts of the direct violence 

1 Pouteau : GEuvres posthumes, 1783, vol. ii. p. 258. 



FRACTURES OF THE BONES OF THE FOREARM. 291 

which has caused the fracture, the doubt can be removed by noting that 
pain at that point is aroused by the effort actively to extend the elbow 
against opposition. If the radius remains entire and is not dislo- 
cated at either end, there can be no shortening of the limb, no over- 
riding of the fragments, and displacement, if present, must be recog- 
nized by following the outline of the bone with the finger. Crepitus 
and abnormal mobility may be obtained by grasping the limb above 
and below the fracture and making pressure alternately upon the frag- 
ments with the fingers, or by seizing the fragments between the thumb 
and fingers and moving them forward and backward upon each other. 
An important and not infrequent complication is dislocation of the 
head of the radius forward ; it should always be suspected when there 
is marked displacement of the fragments of the ulna or unusual swell- 
ing at the elbow. 

Fig. 165. 




Fracture of ulna, with dislocation of head of radius forward. 

The prognosis is good as regards repair and preservation of function. 

Reduction. Reduction can be made only by appropriate pressure upon 
the displaced fragments, traction being practically without value. The 
displacement which it is most important to overcome is the lateral one 
toward the radius, and that should be met in the same way as after 
fracture of both bones, that is, by pressing the thumb and fingers in 
between the bones. 

As the radius acts as a splint to prevent overriding of the fragments 
the surgeon's chief care is to secure immobility and prevent lateral or 
angular displacement. This can be done by the anterior and posterior 
splints used in fracture of both bones, or by a rectangular splint fast- 
ened against the inner side of the arm and semi-pronated forearm, or 
by a moulded plaster splint. In some cases it may be necessary to 
keep the forearm supinated, and in others the bruising of the soft parts 



292 FRACTURES. 

may be so severe as to forbid the use of splints at first. The arm 
should be kept in a sling and the same precautions should be taken to 
avoid undue pressure by the sling upon the ulna as when both bones 
have been broken. A pasteboard, felt, or plaster gutter may be used 
to avoid this danger. 

C. Fracture of the Shaft of the Radius. 

As far as can be judged from general impressions and statistics that 
are somewhat scanty, isolated fracture of the shaft of the radius is less 
frequent than that of the ulna, and appears also to be generally caused 
by direct violence, sometimes by a fall upon the hand. In three cases 
reported by Falkson ? fracture in the middle third with angular dis- 
placement forward was caused by pressure along its longitudinal axis, 
the palm of the hand in dorsal flexion and the back of the elbow 
having been caught between heavy objects which were approaching 
each other. Occasionally it has been broken by muscular action — 
forcible rotation. 

Displacements. The displacements vary somewhat with the seat of 
fracture, the causes being the fracturing force and the action of the 
biceps and pronator muscles. The more common displacement appears 
to be an angular one, the apex of the angle directed forward and inward. 
Plate XX. represents an extreme form. 

The possible loss of supination in consequence of union with a rota- 
tory displacement, the upper fragment being completely supinated by 
the biceps while the lower is kept partly pronated by the dressings, 
which was pointed out by Lonsdale, and has been spoken of in the sec- 
tion on fracture of both bones, is also to be borne in mind after frac- 
ture of the radius alone, especially if the seat of fracture is above the 
insertion of the pronator teres, and is to be met, if at all, in the same 
manner, that is, by keeping the forearm supinated, but it does not appear 
to interfere noticeably with function. 

If the fracture is at or below the middle of the bone the tendency of 
the biceps and pronator teres is to draw the lower end of the upper 
fragment forward and inward, and that of the pronator quadratus and 
supinator longus is to draw the upper end of the lower fragment toward 
the ulna. 

Overriding has been observed only when dislocation of the lower 
end of the ulna was associated with the fracture. 

Diagnosis. The diagnosis is made by recognition of the displacement, 
if it exists, of crepitus and abnormal mobility obtained by grasping 
the fragments with either hand and moving them upon each other or 
by placing a thumb upon the head of the radius and rotating the wrist 
gently. 

Treatment. The indications for treatment are the same as after frac- 
ture of both bones, except so far as the uninjured ulna may be utilized 
as a splint or as its dislocation may require more or less prolonged 
traction. If displacement exists the fragments should be pressed 
back into place as before described, and if the fracture is low down 
and the lower fragment is inclined toward the ulna it will perhaps be 

1 Falkson : Centralblatt fur Chirurgie, 1885, p. 913. 



PLATE XX 




Fig. l.-Fraeture of Radius; Marked Angular Displacement. 




Fig. 2 .-Recent Colles's Fracture in a Boy Twelve Years Old 
showing Epiphyses. 



FRACTURES OF THE BONES OF THE FOREARM. 29:5 

found easier to bring it back into line by drawing the hand forcibly 
downward and toward the ulnar side than by pressing the fingers in 
between the bones. Traction at the wrist and elbow may be required 
to overcome dislocation of the lower fragment upward from the ulna. 

The arm should be secured upon well-padded anterior and posterior 
wooden or moulded splints in the semi-pronated position. Dislocation 
at the lower radio-ulnar articulation or change in the direction of the 
lower articular surface of the radius may make it desirable to use a 
moulded splint that will include the hand and perhaps the lower part 
of the arm, or a long rectangular one for the purpose of extension and 
counter-extension, or to keep the hand inclined toward the ulnar side. 

3. FRACTURES IN THE VICINITY OF THE WRIST. 

A. Fractures of the Radius. Colles's Fracture. 

Under this term are included fractures of the radius near the wrist, 
which, while differing from each other in many respects, have in com- 
mon a characteristic deformity, and often a certain difficulty in making 
reduction. 

Next after the ribs the lower end of the radius is the part of the 
skeleton most frequently broken. While the fracture occurs at all 
ages, it is most frequent in the elderly. It is very remarkable, and 
worthy of mention as a proof of the difficulty of diagnosis in fractures 
near a joint, as well as of the force of authority and tradition, that the 
real nature of this common injury which comes so frequently under 
the notice of all surgeons should not have been recognized, and that it 
should have been taken almost always for a dislocation of the wrist 
backward, until about one hundred years ago. The first mention of 
the injury as a fracture is generally attributed to J. L. Petit, but, I 
think, incorrectly, for I find no reference to it in his chapter on frac 
tures, while the chapter on dislocation of the wrist contains a very good 
clinical description of it. 

Pouteau 1 is the first author to describe it as a fracture and to point 
out the previous universal error in diagnosis. He describes its pathol- 
ogy, attributes its production to the violent contraction of the prona- 
tors, and gives its symptoms and treatment, adding that there is, per- 
haps, no fracture so easy to recognize at a glance. The fact that he 
includes in his description fractures of both bones does not, I think, 
diminish the credit due him for his recognition of the error of his pred- 
ecessors and contemporaries. His view of the subject does not appear 
to have commended itself to his immediate successors, and, during the 
thirty years following its publication, only an occasional mention is 
made of even the possibility of such a lesion, and the common injury 
was still deemed a dislocation. 

The next writer upon the subject failed in like manner to impress 
his opinion upon his immediate contemporaries, and although justice 
was ultimately done him, and the fracture is now known widely by his 
name, the recognition did not come until after his death. Mr. Colics 

1 Pouteau : CEuvres postliumes, 1783, vol. ii. \>. 251. 



294 FRACTURES. 

published his brief but accurate account of the fracture in 1814/ but 
Dr. R. W. Smith, writing in 1847, 2 says: " Subsequent authors have 
repeated what Mr. Colles had said upward of thirty years since, but 
no writer (as far as I have been able to ascertain), not even the distin- 
guished author of the Surgical Dictionary, has alluded to his account 
of the injury." 

Sir Astley Cooper, in the second edition of his Dislocations and Frac- 
tures of the Joints, published in 1823, describes fracture of the lower 
end of the radius, and adds that he had seen this injury frequently, 
but did not understand its nature until taught by dissection ; but he 
describes at the same time dislocation of the wrist, and evidently did 
not appreciate the full character and frequency of the fracture. In a 
subsequent edition he describes experiments made by himself upon the 
cadaver in 1833, in which he produced the fracture by hyperextension 
(extreme dorsal flexion) of the hand. The same failure to appreciate 
the character of the common injury which was coming so frequently 
under the care of every surgeon persisted, notwithstanding the publi- 
cations of Pouteau and Colles, that of the former being entirely over- 
looked apparently, and that of the latter remembered only by the 
Dublin surgeons, who believed in the fracture and gave his name to it. 
But the misapprehension was not destined to last long ; the great change 
which took place in the science of medicine at the beginning of the 
present century under the inspiration and guidance of the French 
physicians, the substitution of objective knowledge for dogma, of clinical 
and dead-house observation for pure speculation, made short work of 
this error. Dupuytren was the first to call attention to it and to impress 
it upon the profession ; a post-mortem examination in 1820 showed 
him the real character of the injury, and his hospital service gave 
him the clinical opportunities that were needed for study and demon- 
stration. A short period of doubt followed, and then, about 1830, 
the fact was universally accepted, and the second stage — that of dis- 
cussion of details, which has lasted until the present time— was 
entered upon. 

Mr. Colles, who had never had an opportunity to dissect a specimen 
of the fracture, speaks only of the symptoms and treatment. His only 
statement concerning the fracture itself is an incorrect one: "This 
fracture takes place at about an inch and a half above the carpal 
extremity of the radius." We now know that, while the line of frac- 
ture may lie at the point he mentioned, it is usually much lower, and is 
often associated with comminution of the lower fragment. The aver- 
age distance is differently estimated, possibly because some have meas- 
ured from the articular edge of the bone and others from the styloid 
process; but the weight of testimony places it at from one-third to 
three-fourths of an inch above the articular border. In the young it 
sometimes follows the epiphyseal line. Its direction is usually trans- 
verse, but it may be oblique laterally or antero-posteriorly, and the 
lower fragment is often comminuted. The lower fragment is some- 
times displaced bodily backward without crushing, as in Figs. 166 and 

1 Colles : Edinburgh Med. and Sur°r. Journal, April. 1814, vol. x. p. 182. 
a K. W. Smith: " Fractures in the Vicinity of Joints," Am. ed.. p. 129. 



FRACTURES OF THE BOXES OF THE FOREARM. 



296 



167, but the displacement appears more often to be almost entirely 

angular, the lower fragment turning upon its anterior edge as upon a 



Fig. 166. 



Fig. 167. 



Fig. 168. 






Fracture of the lower end of the 
radius. Displacement backward. 
(R. W. Smith.) 



Fracture of the lower end 
of the radius. Displacement 
of lower fragment backward. 
(R. W. Smith.) 



Fracture of the lower 
end of the radius. Angu- 
lar displacement of the 
lower fragment back- 
ward with impaction. 
(R. W. Smith.) 



hinge, crushing or penetration with impaction taking place posteriorly 
and outwardly, and the articulating surface looking downward and 
backward instead of downward and forward as it does normally ; 
at the same time the styloid process rises to a higher level. An 
extreme example of this displacement, with union, is shown in 
Fig. 168. Sometimes the styloid process of the ulna is broken off, 
apparently by avulsion through the lateral ligament or possibly the 
fibro-cartilage. Some authors have noted this complication in more 
than half of their cases ; it has appeared in less than 10 per cent, of 
my skiagrams. 

Specimens of recent fracture are not very common, and many of 
those we possess are open to the objection that the fractures have been 
caused by violence far in excess of that which causes the great majority 
of the fractures met with clinically, the patients having falling from 
a considerable height, and having received other injuries that caused 
death within a short time thereafter. Others are obtained from elderly 
patients who have received the fracture in the usual manner, that is, 
by a fall upon the ground while walking, and have then died in a few 
days of an intercurrent affection, usually pneumonia. 

The lioutgen rays have recently added to our knowledge ot' the 
details, showing that the surface of fracture is rarely flat and trans- 
verse, that comminution or splitting of the lower fragment is frequent 
even in early adult life, and that the displacement backward of the 
fragment is not commonly so marked as has been supposed from the 
appearance of the limb. They confirm the opinion that the radial side 



206 



FRACTURES. 



of the bone is shortened and show that the carpus preserves its relations 
with the articular surface of the radius, passing slightly upward toward 
the radial side of the ulna and thus making the latter prominent. In 
marked backward displacement the ulna accompanies the fragment. 

The figures of Plates XX.-XXYI. show the different levels at 
which the fracture occurs, the frequency and character of the comminu- 
tion, the difference in dorsal displacement, and the marked dorsal pro- 
jection of the first row of the carpus in one. Plate XXVII., fig. 1, 
shows arrest of growth after fracture at the age of twelve years, the 
patient being nineteen years old when the picture was taken. Plate 
XXVIII. shows the normal wrist in the adult male and female ; the 
notably lower position of the articular surface of the radius as compared 



Fig. 169. 



Fig. 170. 





United fracture of the radius. 
Smith.) 



(R. W. 



Recently united fracture of the lowei end 
of the radius. (R.W.Smith.) 



with that of the ulna in the female was found in most of the female 
cases examined. 

In specimens obtained after repair has taken place without reduction 
of the displacement the penetration of the posterior portion appears very 
marked (Fig. 169), often more so than it really is. The appearance is 
due in part to the formation of callus upon the posterior face of the 
upper fragment under the periosteum which is stripped up, the " peri- 
osteal bridge/' which is so often found at one side of a fracture, and 
in part to condensation of the spongy tissues during repair. 

Among the lesions that may be associated with the principal fracture 
are fracture of the ulna near its lower end, fracture of the styloid 
process of the ulna, rupture of the radio-ulnar and intra-articular liga- 
ments, and perforation of the skin by the ulna. The first is rare, and 
all the others are the consequence of the momentary prolongation of 
the action or variation in the degree of the fracturing force. The 
Rbntgen rays show the fracture only occasionally, and then only 
as the breaking off of the tip of the process, so that I think it probable 
that the more extensive injuries heretofore noted were in cases charac- 



PLATE XXI 




Fig. 1— Recent Colles's Fracture; Male, Twenty-two Years. 
Same as Plate XXV, Fig. 1. 




Fig. 2.— Old Colles's Fracture. 



PLATE XXII 




Fig. 1.— Recent Colles's Fracture; Comminution; Male, Forty-five Years. 




Fig. 2.- 



■Reeent Colles's Fracture; Comminution 
See also Plate XXV. Fia. 2. 



Male. Fonv Years 



PLATE XXIII 




Fig. 



1.— Recent Colles's Fracture; Male, Twenty-six "Years. 
from a height of four feet. 



Fall 




Fig. 2.— Same as Fig. 1. Side view. 



PLATE XXIV 




Fig. 1. — Same as Plate XXIII. After reduction. 




Fig. 2.— Recent Colles's Fracture; Male, Fifty-six Years 
Fall from a height. 



PLATE XXV 




Fig. 1.— Recent Colles's Fracture; Male, Twenty-two Years. 
Same as Plate XXI, Fig. 1. 




Fig. 2.- 



■Reeent Colles's Fracture. Male. Forts Years. 
Same as Plate XXII. Pig. 2. 



PLATE XXVI 




Comminuted Colles's Fracture. 



PLATE XXVII 




Fig. 1.— Arrest of Growth of Radius after Colles's Fracture at age of 
Twelve Years. Present age, nineteen years. 




Fig. 2.— Separation of Radial Epiphysis; Boy. Fifteen Year?. 



PLATE XXVIII 




Fig. 1. — Normal "Wrist; Adult Male. 




Fig. 2.— Normal Wrist; Adult Female. Fracture of Third Metacarpal. 



FRACTURES OF THE BONES OF THE FOREARM. 207 

terized by greater causative violence and wider displacement. The 
mechanism appears to be avulsion through the cord-like lateral liga- 
ment which is attached to its tip. 

Concerning the condition of the intra-articular fibro-cartilage I can 
find but little that is positive, since the only sources of information are 
the autopsies of recent fractures. The Rontgen rays give no direct 
information on this point, for the cartilage is transparent to them ; its 
avulsion from the ulna or- radius seems inevitable when the lower end 
of the radius is markedly displaced. 

Although much stress has been laid by some upon the supposed 
rupture of the internal lateral ligament, fresh specimens and experiment 
upon the cadaver give no ground for the belief that it occurs except in 
cases with marked displacement. The fact that the end of the ulna is 
prominent and that the finger can be pressed in on the side below it 
much more deeply than in a normal joint can be explained by the 
ascent of the carpus, which would draw the ligament to a more trans- 
verse position. 

I believe that in the severer cases the tendon of the extensor carpi 
ulnaris is torn out of its sheath and displaced outwardly from the ulna, 
for I have noted in such cases the absence of the resistance which the 
tendon normally offers to the finger close below the joint. 

I have not met with the record of any case in which the radius pro- 
jected through the skin, except after separation of the epiphysis, but I 
have seen fractures compound on the radial side. 

Associated fracture of the scaphoid has been observed in a number 
of clinical and experimental cases, and that of the semilunar (Hunt) 
and dislocation of the semilunar (Cameron) have been reported. (See 
Fractures of the Carpus.) Also injury of the median nerve by stretch- 
ing across the edge of the upper fragment, of which Blecher 1 collected 
nine cases. The symptoms usually appeared after an interval. 

Cause. The cause of Colles's fracture is usually a fall upon the palm 
of the hand, and in the great majority of cases the fall is only to the 
ground while walking. This is true of almost all cases in which the 
patients are somewhat advanced in life ; in the younger ones the vio- 
lence is usually greater, as a fall from a height. 

The mechanism by which the fracture is produced has been the 
subject of much discussion. Three theories have been advanced : 1. 
Fracture by splitting or crushing; the cancellous tissue is crushed or 
comminuted between the carpus and the diaphysis. 2. Fracture as in 
other bones by decomposition of the force and yielding at the weakest 
point. 3. Fracture by cross-strain exerted through the anterior liga- 
ment in exaggerated and forced dorsal flexion (hyperextension) of the 
hand. I believe that almost all these fractures are produced accord- 
ing to one or the other of the first two ways, and that the third is rarely 
seen. 

In the first the weight of the body is received upon the ball oli the 
hand — the carpus — directly in the line of the long axis of the radius. 
and the inner end of the scaphoid or the semilunar splits the end o\' 

1 Blecher: Deutsche Zeitscrift fur Chir., vol. 93, p. 34. 



298 FRACTURES. 

the radius like a wedge. This is shown by many specimens and appears 
to be especially frequent in the elderly. 

In the second the line of the force is slightly inclined from the long 
axis of the radius, making an angle open anteriorly. The arm is out- 
stretched and not directly in the line of the fall. The force is decom- 
posed as usual, part being taken up by the resistance of the shaft in the 
long axis, and part acting transversely to break the bone. The back- 
ward displacement and tilting of the lower fragment indicate the direc- 
tion of this component. 

According to the third theory a cross-strain is exerted upon the end 
of the bone through the anterior ligament of the wrist ; the force is 
thought to be received upon the palm of the extended hand at a point 
that lies posterior to the posterior border of the end of the radius, the 
hand is bent back, the ligament is put upon the stretch, and the bone 
is broken by avulsion. The theory seems to have originated in experi- 
ments upon the cadaver. The earliest recorded experiments in this 
direction were those already alluded to which were made by Sir Astley 
Cooper in 1833, but not published until several years afterward ; the 
earliest publication appears to have been by Bouchet 1 in 1834. The 
experiment may produce a transverse fracture within a short distance of 
the articular surface of the radius, but quite as often it causes rupture 
of the anterior ligament and even dislocation or fracture of one or 
more of the carpal bones. There is no doubt, therefore, that the frac- 
ture can be produced in this way, and there are a few clinical cases in 
which this was apparently the mode of production. But, with the 
exception of these few cases, in which the mode of action of the vio- 
lence was distinctly exceptional, there is nothing but the experiments 
to support the theory. In other clinical cases the same movement has 
produced dislocation of the semilunar or fracture of the scaphoid or 
semilunar. (See also Poulsen, Arch. kiln. Chir., vol. 80, p. 902, and 
Cartruccio, Bdtrage zur Min. Chir., vol. 53, p. 66.) 

The violence in a fall is not usually received at a point on the palm 
of the hand posterior to the line of the radius so as to bend the hand 
backward ; it is received at the base of the thumb, at a point corre- 
sponding to the trapezium, or along the carpus, and is transmitted 
directly to the radius as above described. Moreover, the theory fails 
to explain the comminution so frequently seen and fractures above the 
conjugal cartilage in the young. 

Symptoms. The symptoms are marked and characteristic, but crep- 
itus and abnormal mobility, so common in other fractures, are not 
always easily recognizable in this. The most striking features of the 
deformity are the prominence of the dorsum over the lower* fragment 
and that of the end of the ulna. The former so changes the outline 
of the forearm and wrist that when viewed from the radial side its 
appearance is like that represented in Fig. 171, and was aptly com- 
pared by Velpeau to the outline of a silver fork, a comparison which 
has survived in the name "silver-fork fracture," by which it is some- 
times known. The cause of this change in the outline, so far as it is 

1 Bouchet : These sur les Luxations du Poignet. Quoted by Malgaigne 



FRACTURES OF THE BONES OF THE FOREARM. 



209 



due to the position of the fragments, is shown in some of the radio- 
graphs ; swelling of the soft parts and even projection of the first row 
of the carpus accounts for some of it ; that of the palmar aspect is 
due mainly to swelling of the soft parts. 

The radiographs show that the characteristic deformity is present 
even when the displacement of the fragment is slight, and that in 

Fig. 171. 




Deformity in Colles's fracture. 



general this displacement is much less than has heretofore been sup- 
posed. 

The prominence of the end of the ulna appears to be due to the 
displacement of the carpus and the fragment of the radius upward 
and somewhat to the radial side, aided sometimes by avulsion of the 
styloid process of the ulna, or, possibly, the equivalent rupture of the 
internal lateral ligament. That ascent of the end of the radius is 
sufficient to produce this prominence is shown by its gradual appear- 
ance in cases of arrest of growth at the lower end of that bone. (See 
Plate XX^V II.) 

If the surgeon marks the positions of the styloid processes by press- 
ing the end of a finger into the side of the joint below and against the 
end of each, he will see that that of the radius has risen, so that 
instead of being about a quarter of an inch lower (nearer the hand) 
than that of the ulna, as it usually is, it has risen to the same level, or 
even above it. 

The swelling upon the anterior surface of the forearm is quite 
marked, and is sharply rounded off .toward the wrist with deepening 
of the transverse creases. 

Crepitus and abnormal mobility can sometimes be obtained by 
grasping the lower fragment between the thumb and fingers and mov- 
ing it backward and forward while the forearm is steadied by the 
other hand. 

Pressure along the line of fracture on the dorsum of the radius or 
of the hand upward against the forearm is painful. 

Diagnosis. The diagnosis is made by recognition oi" the above signs 



300 FRACTURES. 

and symptoms. In difficult cases, fat people and children without 
displacement, it may be made upon the existence of a well-defined 
transverse line of tenderness on pressure on the dorsum of the radius, 
pain at the same point when the hand is pressed upward against the 
radius, deepening of the transverse folds on the palmar aspect of the 
wrist, loss of power in the limb, and history of the case. Care should 
be taken not to confound it with or overlook coincident fracture of 
the scaphoid. 

A sprain or contusion may be mistaken for a fracture if the limb 
has been broken previously and has united with deformity, for it will 
present some of the physical and functional signs. The question 
therefore should always be asked whether the wrist has suffered a pre- 
vious injury. 

Course and Prognosis. Firm union between the fragments may be 
expected within a month. The prognosis with reference to deformity 
depends, of course, upon the completeness of the reduction and reten- 
tion. As a rule, permanent deformity after fracture in youth is slight 
or entirely absent ; but in adults the case is different, either because 
the original displacement is greater, or because crushing and comminu- 
tion make complete reduction and retention practically impossible. 

The prognosis with reference to function is somewhat better, since 
the persistence of even marked displacement does not necessarily 
entail disability. The range of motion at the wrist may be somewhat 
restricted, and yet may be wide enough to answer all purposes, and a 
change in the direction of the articular surface is still compatible with 
free and painless motion. Restriction of supination is common for 
some time after recovery, presumably because of infiltration of the 
pronator quadratus. Rigidity of the wrist and fingers usually persists 
for some weeks, or even months, and in exceptional cases, in the old 
and rheumatic and in those where there has been much inflammation 
of the sheaths of the tendons and of the wrist-joint, it may persist for 
years. Our recently gained knowledge of fracture of the scaphoid 
suggests that the disability in some of these reported cases has been due 
to the co-existence of that injury. I have seen two cases in which the 
hand was practically useless a year or two after the receipt of the injury. 
There was much deformity in one of them. This rigidity of the fingers 
is due in part to their prolonged immobilization and in part possibly to 
inflammation within the sheaths of their tendons in the forearm. 

The possible arrest of the growth of the bone after separation of the 
epiphysis in the young deserves mention, although it is an exceptional 
consequence of the injury. I have seen two such cases. (Plate XXVII), 

Treatment. Complete reduction of the displacement is, of course, 
essential to prevent permanent deformity. The ease a\ ith which it can 
be accomplished varies greatly in different cases. Traction upon the 
hand with direct pressure upon the fragment is sometimes sufficient to 
correct the dorsal displacement; in other cases forcible pressure must 
be made, the forearm is grasped with the fingers upon the palmar 
prominence and the thumbs upon the dorsal one, and the pieces pressed 
into line. Occasionally an anaesthetic must be given and the fragment 



FRACTURES OF THE BONES OF THE FOREARM. 301 

mobilized by moving it forcibly backward and forward and then press- 
ing it into place. 

In order to meet the two indications — the prevention of posterior 
displacement of the lower fragment and of projection of the end of the 
ulna — a. great variety of splints have been devised, most of them upon 
the theory that the position of the fragment can be controlled by the 
attitude given to the hand. Thus, palmar flexion of the wrist has 
been employed to prevent backward displacement of the fragment of 
the radius, and ulnar flexion to prevent the prominence of the ulna. 
The theory is wrong and the results have disappointed. If the dorsal 
displacement has been corrected it has little tendency to recur, and the 
attitude of the hand is without influence upon it ; the projection of the 
end of the ulna cannot be prevented by ulnar flexion of the wrist, for 
this movement does not bring back the carpus and the radial fragment 
to their normal positions. 

The facts to be borne in mind are : 1. That dorsal prominence of the 
fragment is to be prevented by correction of the displacement before 
the application of a dressing, and its recurrence prevented by direct 
action upon the fragment, not by indirect action through the hand. 
2. That some permanent shortening of the radius, especially on its 
outer side, if its cancellous tissue has been crushed, as is the rule in 
the old and frequent in others, is inevitable. 3. That the prominence 
of the ulna can be prevented only by bringing the fragment of the 
radius (and thus the carpus) fully back to its normal position — a prac- 
tical impossibility in many cases. Direct lateral pressure upon the 
sides of the wrist may diminish the prominence in some cases. 4. 
That the fingers must be left free in order to avoid the stiffening caused 
by their confinement. 

A suitable dressing, therefore, is one which immobilizes the fragment 
and the carpus in the position given to them and leaves the fingers free 
to be flexed and extended at will ; and as the tendency to recurrence of 
the dorsal displacement is slight special precautions against it are rarely 
needed. 

Such a dressing may be made of plaster-of-Paris or wooden splints. 
The most convenient attitude is that of partial pronation with the wrist 
in slight dorsal flexion and the fingers flexed. There should be two 
splints, palmar and dorsal, the former extending from a little below 
the elbow to the metacarpo-phalangeal joints, the latter from the same 
height to the carpo-metacarpal joints. 

Wooden splints (Fig. 172) should be three inches broad and padded, 
the padding being a little thicker on the palmar splint at the point cor- 
responding to the lower end of the upper fragment, and on the dorsal 
splint at the point corresponding to the lower fragment. A roller- 
bandage placed obliquely at the lower end of the palmar splint makes 
a convenient rest for the hand, maintains dorsal flexion of the wrist, 
and permits the fingers to be clasped over it. The splints are secured 
in place by two adhesive bands, one at each end, and by a roller- 
bandage. 

Plaster-of-Paris splints (Fig. 173) should be wide enough to cover 
in the wrist, and the lower end of the palmar one may bo conveniently 



302 



FRACTURES. 



made into a roll to fill the palm of the hand. The dorsal one may 
extend upon the back of the hand. They should be secured in place 
by a roller-bandage, and while the plaster is setting it may be held 
snugly against the sides of the wrist so as to keep the ends of the 
radius and ulna close together. They are especially advantageous in per- 



Fig. 172. 




Wooden splints for Colles's fracture. 

mitting daily massage of the parts : the dorsal splint is removed and 
massage made on the uncovered portion from the beginning, and the 
palmar one can be removed for the same purpose (the dorsal one being 
kept in place) after the first week. The patient must be instructed to 
keep the fingers flexed when at rest, and to move them frequently. 
It is well also to keep the thumb abducted. 

Fig. 173. 




Plaster-of-Paris splints for Colles's fracture. 

The question sometimes arises whether the deformity, persisting for 
some time after the injury and the result of an error in diagnosis or of 
failure of treatment, can be corrected. Among Dupuytren's earliest 
cases were three of this kind, and he succeeded in overcoming the 
deformity by steady forcible traction and pressure upon the fragments 
on the twentieth, twenty-ninth, and thirtieth days after the receipt of 
the injury, the patients being respectively sixty-nine, ten, and thirteen 
years old. A few cases have been treated by refracture or by incision 
and osteotomy. • I doubt if anything more than an improvement in 
appearance can be gained thereby ; the causes of loss of function can-, 
not be thus removed. 



B. Fractures at the Wrist Other than Colles's. 

Dr. Rhea Barton, 1 of Philadelphia, described clinically a fracture 
which he said was very common, and which he supposed to be the 
detachment of the posterior border of the articular surface of the 
radius. It does not appear from his paper that he had ever had an 

1 Barton : Medical Examiner, 1838, p. 365. 



FRACTURES OF THE BONES OF THE FOREARM. 303 

opportunity to verify the diagnosis by examination. A few specimens 
of such a fracture, most of them, I believe, found in the dissecting- 
room and without history, are in existence, and the injury is known in 
America as Barton's fracture. Dr. Agnew l figures a specimen in which 
the fragment is much larger. It is perhaps hardly worth while to try 
now to change this name, but there are three good reasons why the 
injury should not be known as Barton's fracture : 1st, as a reference to 
the original article shows, the injury which Barton described clinically 
was not what he supposed it to be anatomically, but was the ordinary 
Colles's- fracture ; 2d, the lesion as he supposed it to be, had been 
observed some years before his paper was published, and the specimen 
was presented by Lenoir 2 to one of the Paris societies; and, 3d, it 
deserves to be classed not as a variety of fracture, but as a complica- 
tion of dislocation of the carpus backward. In Lenoir's case, which is 
described as a dislocation by Voillemier and Maigaigne, a narrow frag- 
ment of the posterior articular border had been broken off, remained 
attached to the capsule, and was displaced backward with the bones of 
the wrist. I have seen two such cases. 

An analogous case, dislocation of the carpus forward with detachment 
of the anterior border of the articular end of the radius and fracture 
of the styloid process, was reported, with the specimen, to the Societe 
Anatomique, by Letenneur. 3 The patient was brought to the Hotel- 
Dieu May 7, 1838, having received this injury and also a fracture of 
the scaphoid bone of the other wrist, by falling into a ditch while 
intoxicated. Mr. Callender 4 refers to a somewhat similar specimen, 
but one in which the fragment is much larger, in the following words : 
" The line of fracture is four-tenths of an inch from the end of the 
radius on the palmar surface, but on the dorsal passed into — along the 
edge of — the articular facets." A case demonstrated by the .r-ray is 
reported by Shoemaker. 5 

Other infrequent fractures of the region may be conveniently men- 
tioned here : 

A condition in which, the line of fracture being the same as in Col- 
les's fracture, the lower fragment is displaced toward the palmar side, 
and the crushing is also on that side. Mr. Callender 6 reports such 
a case caused by forced flexion of the hand in a fall upon it ; there 
was a well-marked prominence on the dorsum of the forearm about 
three-fourths of an inch above the wrist-joint, and opposite it on 
the palmar surface was a considerable depression. The lower frag- 
ment of the radius was inclined at an oblique angle to the palmar sur- 
face, and projected at the wrist. No crepitus. Reduction could not 
be effected. Ten months later the deformity persisted, with good rota- 

1 Agnew : Loc. cit., vol. i. p. 905. 

2 Lenoir: This fact is mentioned by Voillemier, in the Archives Generates de 
MMecine, 1839, vol. vi. p. 402, and by Maigaigne. The Society referred to is 
probably the Societe Anatomique, but I have failed to find mention of the specimen 
in its Bulletins. 

3 Letenneur : Bulletins, vol. xiv. p. 162. 

4 Callender : Loc. cit., p. 291. 

5 Shoemaker : Annals of Surgery, August, 1904, p. 2S4. 
<'> Callender: Loc. cit., p. 289. 



304 FRACTURES. 

tion, exaggerated flexion, and inability to extend the hand beyond a 
straight line with the forearm. 

Callender mentions also two specimens, one in the museum of West- 
minster Hospital, the other at St. Bartholomew's, which show the cor- 
responding displacement with union. In one the styloid proeess of 
the ulna was broken and the lower fragment of the radius displaced 
forward and outward, especially in the latter direction, with penetra- 
tion on the palmar surface, to the depth of more than three-tenths of 
an inch. In the other the line of fracture is rather more than an inch 
above the end of the bone ; there is a prominent angle on the dorsal 
aspect in the line of the fracture and an elevation of new bone on the 
corresponding part of the palmar surface ; the triangular fibro-cartilage 
was almost completely separated from the radius. 

R. W. Smith l describes and figures a similar case, in which also the 
fracture was caused by a fall upon the back of the hand, and I know 
of one seen by Dr. Keyes. 

The diagnosis is made by attention to the position of the styloid 
process with reference to the carpus and the ulna and by recognition 
of the line of limited tenderness if mobility and crepitus cannot be 
obtained. The treatment should be the same as in Coiles's fracture, 
except that the position of the pads should be changed to meet the 
different displacements. The subject has been treated in detail by Dr. 
J. B. Roberts in Annals of Surgery, January, 1897 ; see also Idem., 
September, 1904, p. 423, for two cases seen by him and one by 
Stewart. 

An oblique fracture running downward and inward and detaching 
the styloid, process of the radius with more or less of the articular por- 
tion ; the larger the fragment the more closely will the symptoms 
resemble those of Colles's fracture. The injury is rare. In the 
few cases I have seen and in those reported the fragment has been 
quite large. Usually the displacement is slight, but in one case the 
fragment was drawn upward one and a half inches. Immobilization 
of the wrist appears to be all that is needed. 

Longitudinal fracture or fissure of the end of the bone. Dr. Bigelow 2 
reported one case and referred to a second. There was a star-shaped 
crack on the articular surface without displacement and slight corre- 
sponding cracks in the shaft for more than an inch above. At first 
there was only lameness at the wrist, but after several days there were 
swelling and tenderness, the persistence of which led Dr. Bigelow to 
make the diagnosis. He had had a similar case two years before, with 
the same symptoms, but less extensive injury to the bone. I have seen 
one, shown by skiagram. It is clearly an incomplete Colles's ; if the 
violence had been greater the fracture would have been the usual one. 

Fracture of the styloid process of the ulna is sometimes observed sepa- 
rately as the result of direct violence. In addition to the usual symp- 
toms of pain and swelling, mobility of the process could probably be 
recognized by direct manipulation or by abduction of the hand. Dr. 
Agnew says some deformity is likely to remain, and that in the only 

1 E. W. Smith : Loc. cit., p. 162. 

2 Bigelow : Boston Med. and Surg. Journal, 1858, vol. lviii, p. 99. 



FRACTURES OF THE BONES OF THE FOREARM. 305 

case he had seen the union was fibrous. He advises treatment upon an 
anterior splint with the hand inclined toward the ulnar side and in 
dorsal flexion, so as to relax the extensor carpi ulnaris. 

Fracture of both bones near the wrist is occasionally seen. The diag- 
nosis is made by recognition of the abnormal mobility of the fragments. 
Treatment as in Colles's fracture. 

In compound fractures every effort should be made to avoid ampu- 
tation. Good results have been obtained even by excision of the lower 
end of the ulna alone or of both bones. 

20 



CHAPTER XXI. 

FRACTUEES OF THE CARPUS AND HAND. 

Fractures of the Carpus., of the Metacarpal Bones, and of the Phlanges. 

1. FRACTURES OF THE CARPAL BONES. 1 

(See Plates XXIX-XXXII). 

The findings of the a'-rays in the last decade and the clinical obser- 
vations which they have stimulated and made possible have brought to 
our knowledge in detail many lesions of the carpus which were hereto- 
fore unknown or known only incompletely and as of rare occurrence. 
The anatomical and physiological complexity of the carpus leads to a 
corresponding complexity of the traumatic lesions which occur in it 
and of the combinations which may be produced in accordance with 
the many variations in the direction, extent, and prolongation of the 
force which produces them. Fractures and dislocations of the different 
bones which compose the carpus may occur singly or in various com- 
binations, and while some of the single injuries and some of the combi- 
nations occur frequently and regularly enough to justify systematic 
description, others are so few or so variable and so dependent upon 
varying mechanical conditions that they defy analysis and classification 
and must be recorded only as isolated facts. 

The two most frequent lesions are fracture of the scaphoid and dis- 
location of the semilunar. Of each of these many clear uncomplicated 
instances have been observed, and yet the two are not infrequently 
combined, and often in association with various derangements of the 
mutual relations of the other bones, in such a way as to lead some in- 
vestigators to believe that this combination should be regarded as the 
type, and the frequent lesser individual injuries as minor forms of or 
deviations from it. Thus, a frequent combination is fracture of the 
scaphoid with dislocation forward of the proximal fragment together 
with the semilunar and a displacement backward of the os magnum 

1 Bibliography.— Letenneur, Bull de la Soc. Anat., 1839, vol. xiv. p. 162; Guibout 
ibid., vol. xxii. p. 27- Flower, Holmes's Syst. of Surg., Am. ed., vol. i. p. 867* Fortu- 
net, Lyon Med., July 1, 1888; Rutherford, Glasgow Med. Jour., 1891, p. 312; Stimson, 
N. Y. Med. Jour., May 21, 1892; Auvray, Gaz. des H6p., 1898, p. 377 ; Sir Wm. Stokes, 
British Med. Jour., 1900, i. p. 1075; Hofiiger, Corresp.-blatt. fur Schweiz. Aerzte, 1901, 
p. 297; Kaufman, Ibid., 1902, p. 257; Stimson, Annals of Surg., May, 1902; Pagen- 
stecher, Munch. Med. Wochenschrift, 1903, p. 1916 ; Wolff, Deutsche Zeitschrift fur 
Chir., 1903, vol. lxix. p. 401; Blau, Ibid., vol. lxxii. p. 445; Lilienfeld, Arch, fur 
klin. Chir., 1903; vol. lxix. p. 1158; Vialle, Arch, de Med. and Phar. Med., Oct., 1904; 
Russ. Annals of Surg., Feb., 1905; Codman and Chase, Annals of Surg., March and 
June, 1905, an elaborate paper; Karrer, Inaug. Diss., Kiel, 1905, abst. in Zentralblatt 
fur Chir. 1906, p. 811; Ehebald, Arch, fur Orthopa>die, Mechanother. und Unfallchir., 
1906, p. 276, with bibliography; Hirsh, Ztlblatt fur Chir., 1906, p. 1289; Cartruccio> 
Beitrage zur klin. Chir., Feb. 1907, p. 66; De Quervain, Monatschrift fur Unfallheil- 
kunde, 1902, vol. 9, p. 65 ; Ebermayer, Fortschritte aus dem Geb. Roentgenstrahlen, 
1908, vol. 12; Shoch. Deut. Ztschrift, fur Chir., 1907-8, vol. 91, p. 53; Delbet, Bull, et 
Mem. de la Soc. de Chir., 1908 ; vol. 34, p. 377; Downes, Annals of Surg., Jan., 1908; 
Ely. Med. Record, May, 1908. 
306 



PLATE XXIX 




Fracture of Scaphoid and possibly of Radius. 



PLATE XXX 




Fracture of the Scaphoid, with Displacement of Proximal Fragment. 



PLATE XXXI 




Fracture of Scaphoid. Profile view of Plate XXX 



PLATE XXXII 




Fig. 1. — Fracture of Carpal Scaphoid.. 




1 



Fig. 2. 



-Separation of Lower Epiphysis of Femur; Displacement forward 
-with Rotation about the Transverse Axis. 



FRACTURES OF THE CARPUS A XL) HAM). 307 

either from its fellows of the second row of the carpus or with them 
from the remaining bones of the first row. Delbet l in an elaborate, 
pathological, clinical and experimental study of the subject, proposes 
that this injury should be termed "dislocation of the os magnum," 
with sub-titles indicating the varieties. The name " dislocation-frac- 
ture of the carpal bones," or "of the intercarpal joint" was suggested by 
De Quervain.' 2 While the existence of this complex type, and even its 
comparative frequency, cannot be questioned, yet I am convinced that 
both fracture of the scaphoid and dislocation of the semilunar occur 
without complications, or, in the case of the semilunar, with only slight 
ones, and that the comprehension of the subject and the readiness of 
recognition of the injury will be promoted by separate descriptions. 
The complex form will be considered in Chapter XLVIII, " Mid carpal 
fracture-dislocation. " 

Scaphoid. — Until within a few years the injury was deemed very 
rare and was known only by a few reported cases and fresh specimens 
obtained at autopsy or by operation, and a few museum specimens of 
old fractures obtained by chance, of some of which it. was claimed that 
they might be examples of a rare developmental variation, the " navicu- 
lar bipartitum." After the existence of the fresh fracture had been 
shown by the x-rays and the clinical recognition had become easy the 
number of reported cases rapidly increased and its frequency is now 
Avell established. Doubtless cases were previously thought to be sprains 
or occasionally Colles's fracture, or were overlooked when they co-ex- 
isted with the latter injury. 

The injury is most frequent in males between the ages of twenty and 
forty years. The common cause is violence received upon the ball of 
the thumb, while the wrist is in dorsal flexion, by which the scaphoid 
is pressed directly against the radius. Usually it is by a fall upon the 
outstretched hand, but in a few cases the violence has been received in 
a manner which is identical with that in which the lesion has been 
often produced in experiments, namely, a blow or forcible pressure 
against the ball of the hand in the direction of the long axis of the 
forearm while the back of the elbow rests against solid resistance. The 
few reported cases in which the scaphoid has been broken in forced 
flexion of the wrist apparently belong in the complex form, the " frac- 
ture-dislocation." The character of the violence is so similar to that 
which produces Colles's fracture that the two may probably be deemed 
alternative lesions, the scaphoid breaking in some, the radius in others, 
especially the old whose epiphyses are thinned. This is further con- 
firmed by the fact that occasionally the two fractures co-exist. 

The mechanism of the fracture is not clear. Various explanations 
have been offered, some of which can be true only of the complex eases 
and will not here be considered. Of the others, two seem possible : 
pressure by the head of the os magnum against the proximal halt' of 
the scaphoid, and pressure by the external object against the projecting 

1 Delbet : Bull, et Mem. de la Soc. de Ckir., 190S, vol. 34, p. 877. 
2 De Quervain: Monatschft fur Unfallkeilkunde, 1002, vol. 0. p. 65, 



308 FRACTURES. 

poles of the curved bone, as a curved rod is broken by straightening it. 
The latter seems the probable cause in cases in which the fracture is in 
the distal two-thirds of the bone and the displacement slight, In the cases 
in which the proximal fragment is dislocated forward, pressure by the 
head of the os magnum is apparently the only agency by which the 
displacement could be effected, and it is probable that it would have a 
part in producing the fracture. Unquestionably in these cases with 
dislocation of the fragment there must have been at the moment of 
dislocation some shift in the relations of some of the other carpal bones 
to one another, a fact which, strictly speaking, would bring them within 
the complex class, but the shift is either temporary or so slight as to be 
unrecognizable either clinically or by the a--rays, and I therefore prefer 
to group them with the pure fractures. 

It seems probable that the issue of the production of a Colles's frac- 
ture, a fracture of the scaphoid, or a "fracture-dislocation " is determined 
by the direction in which the force is applied to the limb and the posi- 
sition of the hand. If the hand is bent backward but little beyond 
straight extension, as is common in a fall upon it, the force acts 
obliquely to the line of the radius and breaks it across — Colles's ; if the 
hand is thrown further back and the force is more in the line of the 
forearm, the lower end of the radius is crushed — another form of 
Colles's — or the scaphoid is broken ; if the force is received a little 
further out on the palm of the hand and exaggerates its dorsal flexion, 
the head of the os magnum, which has moved around to the back of 
the semilunar, forces the latter out of place, taking with it generally a 
part of the scaphoid, and permanently changes the relations of other 
bones — " fracture-dislocation." 

The line of fracture is transverse and generally nearer the proximal 
than the distal end of the bone, within the area of articulation with the 
os magnum ; very rarely are there more than two pieces. The separa- 
tion of the fragments is shown by the a-rays to be increased by ulnar 
flexion and diminished by radial flexion of the hand. Failure of union 
is frequent and is probably constant in fracture near the proximal end 
where the line of fracture is wholly or mainly intracapsular ; in the 
distal portion the fracture may leave the blood supply sufficient for 
repair. In the cases in which union is thought to have occurred the 
opinion has been based on the relief of symptoms and the a?-ray find- 
ings, neither of which is entirely sufficient. The associated lesions that 
have been observed are Colles's fracture of the radius, fracture of the 
styloid process of the radius, and forward dislocation of the proximal 
fragment of the scaphoid. 

The characteristic symptom, upon which the diagnosis can be made 
with great certainty, is sharp pain on pressure in the depression between 
the extensors of the thumb, the " anatomical snuffbox." There is no 
definite deformity except swelling ; function is lost or much impaired 
because of pain. If the proximal fragment is displaced forward it can 
be plainly felt in the palmar aspect of the wrist at about the level of 
the styloid process of the radius. 



FRACTURES OF THE CARPUS AND HAND. 300 

As time passes, with or without treatment, the pain diminishes, but 
only to return sharply after some unguarded forcible movement. These 
recidives are thought by some to be characteristic of the injury. 

The diagnosis in fresh cases is made by the history, loss of function, 
and pain in the tabatiere ; in older cases by the same local pain, the long 
persistence of disability, and the absence of characteristic signs of other 
injury or disease. Confirmation by the a>rays is desirable. 

The prognosis is rather unfavorable. At the best there is likely to 
remain some loss of flexion and extension in the wrist, and sometimes 
motion is almost wholly lost. There is reason to hope that with earlier 
recognition and suitable treatment this may be improved, for the limi- 
tation is clearly the result of periarticular retraction due to the arthritis 
set up by the trauma and maintained by the presence of the movable 
and poorly nourished fragment. Many of the observations upon which 
our knowledge of the subject is based have been made in Zander or 
mechanico-therapy establishments to which the patients have gone for 
treatment of the late disability, and a number of the specimens have 
been obtained by the late removal by operation in the hope of relieving 
the stiffness. 

The treatment in the fresh simple cases without displacement which 
at present offers the best prospect is immediate immobilization for 
about a month. A number of successful results in which this means 
has apparently been effective have been published, while those in which 
passive motion and mechanico-therapy have been employed have not 
done well. 

If the proximal fragment has been dislocated forward it should be 
removed through a palmar incision. Several such cases with a good 
result have been reported. I have had one. 

In the old cases, with stiffness, even if pain is absent, both fragments 
should be removed, and possibly the entire first row. Vallas 1 recom- 
mends total excision of the carpus, because in two cases in which he 
left only the trapezium and trapezoid the joint remained stiff. In a 
personal case in which the injury was eight years old and the joint 
quite stiff I first removed both fragments ; no improvement following, 
I removed the semilunar and cuneiform. On removal of the dressings 
the gain was slight, but increased under baking and use. The patient 
was then lost sight of. For this excision of the scaphoid alone a dorsal 
incision just inside of the long extensor of the thumb is convenient. 

The semilunar has been found broken in a few cases on examination 
through an open wound or at autopsy, under great violence and with 
associated injuries of the region. Under the .r-rays it has been found 
to present in a number of cases appearances which were thought to 
indicate recent or remote fracture. Ebermayer 2 gives five such, in 
only one of which the diagnosis seems to me to be beyond serious ques- 
tion. Finsterer 3 reports four personal and thirteen reported eases, but 

i Vallas: Bull, de la Soc. de Chir., 1908, vol. 34, p. 118. 

2 Ebermayer : Fortschritte ans dem Geb. de Roentgnstrahlen, 190S, vol. 12, p. 1. 

a Finsterer: Ztlblatt fur Chir., 1908, p. 1473. 



310 FRACTURES. 

thus far only an abstract of his paper has been published. He gives 
as symptoms shortening of the distance between the base of the third 
metacarpal and the edge of the radius (a difficult measurement) and 
pain on pressing the metacarpal bone upward. He says the prognosis 
is unfavorable in respect of function, and advises extirpation of the 
bone to diminish the later arthritis and stiffening. 

The cuneiform has been occasionally broken in connection with other 
injuries. 

The os magnum has been reported broken at the neck in three cases 
observed clinically, and of course some doubt must remain of the accu- 
racy of the diagnosis. The first case was that of Robert, quoted as 
doubtful in the Traits de Chirurgie of Le Dentu and Delbet from the 
Ann. de Therapeutique de Rognetta, 1845, p. 146. The others are those 
of Moty ( Gaz. des Hop., 1890, p. 634). which seems accurate and of 
Guermonprez, very briefly abstracted in the Rev. de Chir., 1882, p. 81. 
I have seen one case in which the possibility of fracture was suggested 
by pain on pressure over the neck of the bone. Harrigan 1 reports a 
case confirmed by the rc-rays, and two cases have been reported in which 
the x-rays have shown the fracture associated with that of other carpal 
bones. Ebermayer gives x-yslj pictures of a transverse fracture of the 
unciform, and of avulsion of a small piece of the trapezium. 

The pisiform has been reported broken, apparently by forcible con- 
traction of the flexor carpi ulnaris, by Alsberg 2 . The surface of frac- 
ture was parallel to the palmar surface, dividing the bone into a small 
superficial and a larger deep fragment, which corresponds to the in- 
clusion of the superficial portion in the tendon of the flexor and the 
ligamentary attachment of the deeper portion to the. cuneiform. The 
diagnosis was made by the x-rays. The symptoms were local pain on 
pressure and pain on forced ulnar flexion of the wrist. Reunion took 
place. 

2. FRACTURES OF THE METACARPAL BONES. 

While simple fracture of a metacarpal bone is not a very common 
accident, still it is not so rare as some authors have inferred from hos- 
pital statistics. Malgaigne found 16 cases in a total of 2377 fractures 
of all kinds treated at the Hotel-Dieu, a percentage of 0.67 ; Polaillon, 
64 cases in a total of 5517 fractures treated in the Paris hospitals 
during the years 1861-63, a percentage of 1.16. Of Polaillon's 64 
cases, 57 were men, only two were old, and none were infants. 

The third and fourth are most frequently broken, the first and fifth 
least. Simultaneous fracture of two or more is frequent when the 
injury is compound. 

A very few cases of probable separation of the distal epiphysis have 
been recorded, one by Malgaigne, one by Hamilton, and one quoted 
by Polaillon from a thesis by Pichon, the ages being nine, eight, and 
twelve years respectively. There was failure of union in Malgaigne's 
case, but without disturbance of function when last seen, thirteen years 

1 Harrigan: Annals of Surg., Dec, 1908, p. 917. 

2 Alsberg: Zeitschrift fur Orthop. Chir., 1908, vol. 20. 



PLATE XXXIII 




Fig. 1. — Fracture of First Metacarpal. 




Fig. 2.— Fracture of First Metacarpal. 



FRACTURES OF THE CARPUS AND II AM). 311 

after the injury. Bennett 1 has described a variety of fracture of the 
base of the first metacarpal, an oblique fracture by which the palmar 
half of this end is separated and the remainder is displaced more or 
less backward, so that at first sight the injury appears to be a subluxa- 
tion. He collected nine examples. The usual displacement is angu- 
lar, the apex of the angle being directed backward or forward, and at 
the same time the fragments may override longitudinally. Miles and 
Struthers (Edinb. Med. Journal, April, 1904) observed ten cases in 
four years, and Russ (Journ. Am. Med. Assoc, 1906, vol. 46, p. 1824) 
eight in one year. 

Cause. The cause may be direct or indirect violence. When direct 
it is a blow upon the back or even the palm of the hand, a fall or 
blow upon its side, or a crushing force, the hand being caught between 
two solid bodies. The first, second, and fifth metacarpals are the ones 
most frequently broken by direct violence. 

The commonest indirect cause is violence received upon the distal 
end of the bone in the direction of its long axis, by which its normal 
curve is exaggerated and fracture produced, as in a fall upon the 
knuckles or a blow with the fist. Lonsdale reported a case in which 
fracture of the third metacarpal was caused by a fall upon the end of 
the outstretched middle finger. In a case reported by Dupuytren, the 
third metacarpal bone w T as broken by being bent backward in a trial 
of strength, the contestants trying to force each other's wrist back 
with their fingers interlocked. Velpeau saw the same bone broken by 
traction upon the index- and middle fingers with some twisting. 

Symptoms. The symptoms are the deformity due to the displace- 
ment of the distal fragment, abnormal mobility, crepitus, pain, and 
inability to use the fingers. The deformity is usually slight and may 
be wholly masked by the swelling ; abnormal mobility and crepitus 
may be found by flexing and extending the corresponding finger and 
at the same time making pressure upon the palm at the supposed seat 
.of fracture, so as to make the fragments prominent behind. The pain 
can be suddenly and sharply increased by pressing the finger toward 
the carpus. 

The course of the fracture is usually simple, and ends in consolida- 
tion in the course of three or four weeks. The complications which 
occurred in the eighty-one cases collected by Polaillon were inflamma- 
tion of the carpo-metacarpal joint, union with marked displacement, 
fusion of adjoining bones when both were broken, and deviation of 
the extensor tendons by a voluminous callus in one each, and failure 
of union in three. In neglected cases of fracture at or near the knuckle 
suppuration is not infrequent and may so extend as to cause marked 
disability. 

Treatment. The first indication is to prevent a too severe inflam- 
matory reaction if it threatens, and with this object the hand should 
be kept at rest in an elevated position. 

If there is no displacement or tendency thereto, a simple immobil- 
izing dressing of cotton, bound on snugly with a roller-bandage, is suf- 
ficient, the fingers being left free to prevent their stiffening. 

1 Bennett: British Medical Journal, July, 1SS6, p. 13. 



312 FRACTURES. 

A method that has long found favor is to fill the palm with a mass 
of tightly packed cotton or some similar substance, or a ball, over 
which the fingers are closed and fastened down with a bandage or 
adhesive plaster. The flexion of the finger over the firm mass tends 
to draw the knuckle downward, and thus prevent shortening. . The 
support furnished by the adjoining bones is an additional aid against 
displacement, and the back of the hand can be left partly uncovered 
for inspection. 

In fracture of the third and fourth metacarpals the hand may be 
bound upon a dorsal or palmar longitudinal splint suitably padded and 
fastened with a roller, but this plan is unsuited to fractures of the 
second or fifth because the circular compression exerted by the bandage 
tends to cause lateral displacement. 

If continuous traction seems necessary to overcome a tendency to 
displacement the finger may be bound to the adjoining ones for a few 
days, but it is important that immobilization of the fingers, especially 
in the extended position, should be avoided or made as brief as pos- 
sible. 

In Bennett's fracture of the first metatarsal reduction is made by 
strong traction and pressure against the base of the bone ; maintenance 
by splints and adhesive plaster or by plaster of Paris. 

3. FRACTURES OF THE PHALANGES. 

These fractures are usually due to direct violence, and in conse- 
quence are frequently compound or at least accompanied by laceration 
or bruising of the soft parts. A few cases have been reported of frac- 
ture by indirect violence, as in a fall or blow upon the end of the 
finger, or by having the finger caught and fixed while the hand con- 
tinued to move. 

The proximal phalanx is the one most frequently broken, the ter- 
minal phalanx most rarely. 

The symptoms upon which the diagnosis is made in simple fractures 
are mobility and crepitus. 

The progress of the case in simple fracture is toward prompt repair ; 
in compound fractures the suppuration is apt to be prolonged, and 
necrosis of splinters and even of one of the principal fragments is not 
uncommon. 

A well-established rule of treatment of injuries of the hand is to 
save everything that can be saved, but it needs limitation in compound 
fractures of the fingers. While it is desirable to save the thumb or 
any part of it, even at the price of anchylosis of both the joints, the 
same value does not attach to the fingers, and a rigid deformed finger 
that has been saved with much difficulty is often a source of so much 
inconvenience that the patient subsequently seeks relief in amputation. 
It is better that members so injured that rigidity will probably result 
should be removed at first, for the attempt to save them cannot be 
made without incurring certain risks, prolonged suppuration, phlegmon 
of the forearm, tetanus, which, although somewhat remote, should not 
be lost sight of. 



FRACTURES OF THE CARPUS AND J1AXI). 313 

In the treatment of simple fracture the usual indication to prevent 
displacement is habitually met by means of a moulded palmar splint 
made of pasteboard, felt, or gutta-percha to which the finger, slightly 
flexed, is made fast. This answers very well for the terminal and 
middle phalanges, but it does not support the proximal one sufficiently. 
Sometimes a straight splint is used, sometimes a plaster-of- Paris 
bandage. 

A common displacement, important to be guarded against, is an 
angular one with the apex directed forward and caused, I think, by 
the action of the interosseous muscles. The persistence of this dis- 
placement constitutes a serious inconvenience, for it limits flexion of 
the metacarpophalangeal joint and creates a prominence upon the 
palmar aspect of the phalanx, the skin covering which may become so 
sensitive that a firm grasp cannot be taken of any hard object. 

As a palmar splint does not entirely prevent this displacement I 
prefer to close the hand upon some firm cylindrical body, a roller-ban- 
dage for example, and fasten the fingers down with strips of adhesive 
plaster applied longitudinally along the back of the hand, the fingers, 
and the front of the forearm, and additionally secured with a few turns 
of a bandage. The roll must be large enough to give ample support, 
and by passing the finger along the dorsum of the phalanx the occur- 
rence of displacement can be recognized. It will be remembered that 
the tendon of each extensor muscle is attached to the base of the prox- 
imal phalanx by a short band which limits the action of the muscle to 
that phalanx, and that the extension of the middle and distal pha- 
langes is accomplished by the interossei, which also flex the metacarpo- 
phalangeal joint and are relaxed when the fingers are closed. The 
tendency to overriding is thus effectively opposed by this position, and 
the displacement which then most needs to be guarded against is the 
one also that is most readily detected, angular displacement with the 
angle directed backward. 

Support that may be sufficient in some cases can be readily obtained 
by binding the broken finger to the adjoining ones and supporting both 
or all three upon a common splint. 

In compound fractures prophylactic doses of tetanus antitoxin have 
been much used, and apparently with good results. 



CHAPTER XXII. 

FRACTURES OF. THE PELVIS. 

Fractures of the Ring of the Pelvis, Sacrum, Coccyx, Ilium, Ischium, Pubis, 
Rim of the Acetabulum. 

Following well-founded custom I group in one section all fractures 
which break the continuity of the ring of the pelvis and consider sepa- 
rately fractures of the individual bones which do not break the con- 
tinuity of the ring. 

1. FRACTURES OF THE RING OF THE PELVIS. 

The most frequent cause of this lesion is the passage of the wheel of 
a heavily laden wagon across the thigh and hypogastrium ; among the 
others are falls upon the feet or the buttocks, the caving, in of an 
embankment, and crushing between the buffers of railway cars or 
other heavy moving objects. The position and the number of the frac- 
tures vary with the degree of the violence and the portion of the ring 
upon which it is received. When it falls upon the symphysis and is 
directed backward the arch yields at its weakest point, and the line of 
fracture passes through the horizontal and descending branches of the 
pubis, sometimes on one side alone, sometimes on both sides. If the 
force then continues to act it presses the sides apart, and either breaks 
the sacrum vertically (by avulsion) or ruptures the ligaments of the 
sacro-iliac synchondrosis, or breaks the ilium into the synchondrosis or 
into the sacro-sciatic notch ; and it does this sometimes also on one side 
alone, and sometimes on both. 

When the violence is received upon the side of the pelvis, or the 
great trochanter, or even upon the foot, it may cause what Malgaigne 
described as double vertical fracture of the pelvis, or fracture of the 
acetabulum to a variable extent, and in one case a fall upon the foot 
caused dislocation of the entire os innominatum, separating it cleanly 
at the symphysis pubis and sacro-iliac joint and forcing it upward. In 
double vertical fracture the anterior fracture occupies the same position 
as when the force has been received upon the symphysis, it crosses the 
pubis ; the posterior one is usually entirely within the ilium and behind 
the acetabulum. In fracture of the acetabulum, which can be caused 
only by violence transmitted through the femur, the bone may be simply 
fissured, or the head of the femur may be driven entirely through into 
the cavity of the pelvis. In the slighter cases the continuity of the 
pelvic ring is not broken, but in the more extensive ones it is. In 
young people the lines of fracture may follow those of the develop- 
mental division of the bone into three. 
314 



FRACTURES OF THE PELVIS. 315 

The displacements arc seldom great, but complications are numerous 
and serious. The most frequent is rupture of the urethra, usually in 
its membranous portion ; among the others are rupture of the bladder 
and laceration of the iliac veins or the external iliac artery. Rupture 
of the bladder may be intra- or extra-peritoneal ; in some cases it 
appears to have been caused by the direct pressure upon the bladder of 
the object which caused the fracture, in others by a splinter or the dis- 
placed fragment. The other two % lesions mentioned are due to the 
displacements. The separation of the pubes tears the urethra across 
at or near the triangular ligament, and the projecting edge of the pos- 
terior line of fracture lacerates one of the iliac veins, or the edge of 
the anterior one tears the external iliac vein or artery. 

In a case briefly referred to by Legros Clark l there were several 
fractures, and separation of the sacro-iliac synchondrosis on each side 
and of the pubic symphysis to the extent of four inches. The rectum 
was ruptured and feces were extra vasated into the pelvis ; the bladder 
was ruptured and the urethra torn completely from the prostate gland. 

The varieties and the symptoms, which vary notably with them, 
require separate mention. 

Separation of the symphysis pubis may be produced by external vio- 
lence directly pressing the anterior superior spines or the ischia apart 
or through forced abduction of the thighs, or by the descent of the 
foetus through the superior strait in parturition. Malgaigne collected 
seventeen cases of the latter, most of them occurring in primiparae, and 
most by the unaided action of the patient's muscles ; in a few cases the 
forceps was used. Usually the separation takes place with a distinct 
cracking sound, and the gap can be felt with the finger, and in one or 
two cases the fracture has been made compound by simultaneous lace- 
ration of the soft parts. The gap is the chief diagnostic symptom. The 
scanty information possessed upon the subject indicates that, in the 
traumatic cases at least, the separation takes place not through the 
cartilage, but between the cartilage and the bone. 

The traumatic cases are no less numerous arid more varied in their 
details, although in a large proportion of them the force seems to have 
been exerted through the adductor muscles of the thighs. In two cases 
quoted by Malgaigne, in a third reported by Weber, 2 and in a fourth 
by Earle, 3 the patient was on horseback and received the injury either 
by being thrown forward upon the withers, or first to one side and then 
to the other, or by the muscular effort made to' keep his seat. In one 
of Malgaigne's cases the results were an immediate hernia, rupture of 
the perineum with a separation at the symphysis that would admit the 
hand, and pain at each sacro-iliac synchondrosis. The patient recov- 
ered in three and a half months, the treatment consisting of a bandage 
drawn tightly about the pelvis, with the limbs resting upon a double 
inclined plane. 

In Earle's case there were collapse, severe pain, flattening of the 
pubes, and free bleeding from the anus. An incision in the perineum 

1 Legros ("lark : Diagnosis of Visceral Lesions, p, ;>:>!'. 

2 Weber: Gaz. Mted. de Strasbourg, 1.872. 

3 Earle: Med. Chir. Trans., L835, vol. xix. p. 257, 



316 FRACTURES. 

gave exit to blood and urine. The patient .survived for only forty 
hours, and the autopsy showed a separation of three inches at the 
symphysis, the left sacro-iliac synchondrosis gaping one inch, and the 
prostate torn completely away from the bladder and hanging down in 
a cavity filled with clot. The patient was between sixty and seventy 
years of age. 

In another singular case quoted by Malgaigne the patient, a lad 
eighteen years old, was learning to be a dancer. His teacher made him 
lie upon his back on the floor with his thighs flexed, and then stand- 
ing upon him with one foot on each knee, sought to force the thighs 
outward. It caused the bones to separate at the symphysis to the 
extent of half a finger-breadth. 

Separation in Front and Behind. In one of Mr. Earle's l cases there 
was complete separation of the left os innominatum, both in front and 
behind ; the bone was forced up to a considerable extent, and the com- 
mon iliac vein torn across. The patient was a young man, and received 
the injury by jumping from a third story ; he landed upon the left foot, 
causing also a compound comminuted fracture of the calcaneum and 
astragalus. 

Similar cases were collected by Malgaigne, and two have been pub- 
lished by Salleron. 2 Creite 3 reports one case and collects seven others. 
The injury has been caused by a fall upon one foot or upon the side of 
the pelvis, or by the pressure of a heavy weight upon the front of the 
pelvis. The characteristic symptom is the elevation of the corre- 
sponding half of the pelvis with absence of the crepitus which is usu- 
ally present in double vertical fracture. Salleron was able to reduce 
the dislocation in his cases, and both recovered, but, as a rule, the 
prognosis is extremely grave. 

Separation of the Sacro-iliac Synchondrosis. Simple separation of this 
joint is very rare. Malgaigne 4 quotes one case of it, and four others 
in which there was in addition fracture of the ilium. I have seen one 
well-marked case. The lesion is said also to have been produced during 
labor. 

The diagnosis is made by recognition of the displacement, which is 
backward and outward. 

Separation of all Three Joints. A few cases have been reported as 
such, but in most there has been also fracture at one or more points, 
and the separation of one or both of the sacro-iliac synchondroses has 
been only the gaping of the joint due to the lateral separation of the 
two halves of the pelvis and not a real displacement. Malgaigne 
quotes briefly five cases, in four of which there were associated frac- 
tures of the pelvic bones. Dolbeau, 5 Dubrueil, 6 and Pollock 7 have 
since reported others. DubrueiFs is the only one in which there seems 
to have been actual displacement at all three points, and even in it 
there was also a slight fracture. The patient was run over by a wagon. 
There was separation of two and a half inches at the symphysis pubis 

1 Earle : Loc. cit., p. 261, Case 5. 

2 Salleron : Archives Gen. de Med., 1871, vol. ii. p. 34, Cases 1 and 2. 

3 Creite: Deutsche Zeitschrift fur Chir., vol. 83, p. 391. 

4 Malgaigne : Loc. cit., vol. ii. p. 777. 5 Dolbeau : Gazette des Hopitaux. 1868. p. 194. 
6 Dubrueil : Ibid., 1871, p. 413. ' Pollock : The Lancet, 1872, vol. ii. p. 409. 



FRACTURES OF THE PELVIS. 317 

and gaping of both sacro-iliac synchondroses. The sacrum was dis- 
placed forward, projecting at the level of the superior strait two centi- 
metres in front of the right ilium and one and a half in front of the 
left. There was a fracture at the junction of the right ischium and 
pubis, and partial fracture of the body of the right pubis. 

In each case the injury was caused by extreme violence acting 
directly upon the pelvis, the passage of a heavy wagon, the fall of a 
heavy object. All terminated fatally. 

Fracture of the pubic portion of the pelvic ring, which is the most com- 
mon of all, passes usually through the horizontal ramus just in front 
of the ilio-pectineal eminence and through the descending ramus near 
its junction with the ischium. The fracture may be oblique or trans- 
verse, may be double (of one or both pubic bones), or may be associated 
with separation of the symphysis or with other fractures of the lateral 
or posterior portions of the pelvis. As has been already mentioned, 
rupture of the ligaments of one or both sacro-iliac synchondroses with 
gaping of the joint is a frequent accompaniment when the action of 
the fracturing force is momentarily prolonged. 

The displacement is sometimes so marked that it can be easily recog- 
nized by the eye ; in other cases the diagnosis can only be made after pal- 
pation of the outline of the bone, which is quite accessible to the touch. 

Interference with the voiding of the urine, either by rupture of the 
urethra or by pressure upon it, is a frequent complication. Injury to 
the urethra takes place usually in the membranous portion. The 
bladder, too, has been sometimes torn by a fragment or ruptured by 
pressure. 

The following are the more noteworthy complications and varieties 
that have been recorded. A man, twenty years old, was run over by 
a railway train and received a fracture of the crest of the right ilium, 
the ramus of the left pubis, and of the " right pubis close to its junc- 
tion with the iliac portion of the bone, the sharp end of this fracture 
had entirely divided the external iliac artery. 7 ' l A man, forty-three 
years old, was run over by a wagon, w r as brought to the hospital insen- 
sible, and died in three hours. There was fracture of the " ramus and 
body of the pubis on both sides, and separation of the sacrum from the 
left os innominatum. Fracture of the left ilium, the fracture extend- 
ing across the pectineal line and causing laceration of the left external 
iliac vein." 2 

Fracture of the lateral portion of the ring occurs in two principal 
forms, one in connection with fracture of the pubic portion, the other 
a fracture radiating from the cavity of the acetabulum. The former 
is the one to which attention was first called by Malgaigne under the 
title of double vertical fracture of the pelvis, a variety of which has been 
described at much length by Voillemier 3 as vertical fracture of the 
sacrum. The posterior line of fracture lies either in the ilium entirely 
behind the acetabulum, or in the sacrum, or partly in the ilium or 
sacrum and partly in the sacro-iliac synchondrosis, and sometimes the 
sacrum is crushed rather than fractured. The cause apparently may 

1 Lancet, 1878, vol. i. p. 347, Case 2. a Lancet, Idem., Case 3. 

:i Voillemier : Cliuique Cliirurgicale, 1862, p. 77. 



318 



FRACTURES. 



be a force acting in either anteroposterior or transverse diameter 
of the pelvis or upward against the tuberosity of the ischium. The 



Fig. 174. 




Double vertical fracture of the pelvis ; united. 

most prominent symptoms in these cases are in the position of the leg 
and in the extent to which it can be moved. The femur is attached 



Ftg. 175. 




Double vertical fracture of the pelvis ; vertical of sacrum, double of pelvis. 

to the portion of bone which is intermediate between the two lines of 
fracture, and as this piece is usually displaced upward and inward 



FRACTURES OF THE PELVIS. 319 

there is apparent shortening of the limb. At the same time the piece 
is commonly rotated about an antero-posterior axis so that the upper part 
of the pelvis is broadened and the lower part narrowed. The inability 
to move the limb is due in part to the lack of a solid support and the 
fear of pain, and in part perhaps to laceration of the muscles of the iliac 
fossa. Pain in the distribution of the obturator nerve is not uncommon. 
The prognosis is unfavorable (35 deaths in 106 cases, Dreschler) because 
of the probability of associated injuries. It may result in lameness 
or in a permanent change in the shape of the pelvis, which in a woman 
may have serious consequences if pregnancy should follow. 

Walther ! describes a variation in which the anterior fracture occu- 
pied the body and descending ramus of the pubis, and the second frac- 
ture ran below the anterior superior spine of the ilium to the sacro- 
sciatic notch ; in addition the upper fragment of the ilium was split 
vertically, and the fifth sacral vertebra was broken. The fragment 
between the two principal lines of fracture was displaced inward and 
had reunited. 

The second form of lateral fracture of the pelvis, radiating fracture 
of the acetabulum and fracture of the floor of the acetabulum are described 
in the following section. 

Vertical fractures of the sacrum are not known except in connection 
with fractures of the pelvic ring at other points, as already mentioned. 
A few cases of very extensive injury have been recorded, extensive 
crushing and multiple fractures. All proved fatal. 

Course and Prognosis. The course and prognosis in all these cases 
depend mainly upon the lesions associated with the fracture. The only 
additional point which requires mention is one referred to by Legros 
Clark, the tendency to suppuration in the loose connective tissue 
between the pubes and the bladder, especially after fracture of the 
pubis or separation of the epiphysis. The uncomplicated and simpler 
forms of fracture tend to easy repair, and even fractures that are very 
extensive are by no means necessarily fatal. 

Diagnosis. The diagnosis is usually easy, but may be very obscure if 
the fracture is limited and without much displacement. The outline 
of the pubis should be carefully followed with the finger to detect irreg- 
ularity or localized pain, and pressure should be made backward alter- 
nately with either hand upon the anterior portion of each ilium in the 
search for abnormal mobility and crepitus. In vertical fracture of the 
sacrum or in separation of the sacro-iliac synchondrosis displacement 
will change the position of the posterior spine of the ilium. In double 
vertical fracture the intermediate portion, which bears the anterior 
superior spine, is usually displaced upward, and the displacement is 
easy of recognition and can be diminished or perhaps reduced by trac- 
tion upon the leg. 

Treatment. In cases without much displacement rest in bed en the 
back is all that is required, aided in the multiple forms or in separa- 
tion at or near the symphysis pubis by a stout girdle drawn snugly 
about the pelvis. Reduction of a fragment of the pubis may some- 

1 Walther: Soc. Anat., October, 1891. 



320 FRACTURES. 

times be made by digital pressure, and that of the intermediate frag- 
ment in double fracture by traction upon the limb aided by pressure 
with the finger from the vagina or rectum. In compound fractures 
loose fragments should be removed. 

Treatment of the complications belongs more properly to the subject 
of general surgery, but the frequency of laceration of the urethra and 
the advantages of its early recognition and treatment are so great that 
it deserves mention. On the first indication of probable injury to the 
urethra the catheter should be introduced, and if its passage is pre- 
vented or even rendered difficult by injury to the urethra, an incision 
should be made through the perineum to the injured part cutting upon 
the end of the catheter as a guide. I have almost always found the 
membranous urethra not only torn across but also so freely separated 
by laceration of the soft parts amid which it lies that its recognition 
was difficult. It is so thin and collapsed and its torn end so shreddy 
that it can hardly be distinguished. For this reason it is desirable to 
make the incision with the aid only of local anaesthesia — cocaine or 
freezing — in order that the patient may aid the recognition by passing 
urine. If possible the two torn ends of the urethra should be united 
by one or two sutures along its roof so as to aid the permanent resto- 
ration of the continuity of the canal ; and each torn end should be split 
for half an inch along the floor so as to avoid the cicatricial narrowing 
which follows circular division. 

If the bladder has been ruptured, intra- or extra-peritoneally, supra- 
pubic cystotomy may be needed to evacuate the escaped urine and close 
the opening or for drainage of the bladder. Permanent catheteriza- 
tion through the perineal opening may sometimes take -the place of 
suprapubic drainage; it is not needed if the bladder is uninjured. 

2. RADIATING FRACTURE OF THE ACETABULUM AND FRACTURE 
OF THE FLOOR OF THE ACETABULUM. 

In the typical form the first three lines of fracture pass from the 
acetabulum across its margin into the sciatic notch, the obturator 
foramen, and across the brim of the pelvis ; the most frequent variation 
seems to be the breaking off of the pubic portion of the brim. An- 
other form of fracture, that of the floor of the acetabulum, seems to be a 
variant of the beginning of the typical form and appears either as a 
slight splintering of the central portion or a more extensive break in 
which the floor is driven inward in several pieces the lines of fracture 
of which extend outward more or less into the adjoining bone. 

As the head of the femur may be forced inward in any of the forms, 
pressing the fragments apart, the term luxatio centralis femorls is fre- 
quently applied to them all, and under that name several articles treat- 
ing of the subject in detail, with collation of reported cases have been 
published. 1 The term has also been applied, but, I think, quite im- 

1 Simon: Beitrage zur klin. Chir., 1905, vol. 45, p. 555; Wolff, Idem., 1906-7, vol. 
52, p. 561, and Worner, Idem, 1907-8, vol. 56, p. 185. See also Guibe, Revue de Chir., 
An. 24, No. I., and Thevenot, Idem, No. II. 



FRACTURES OF THE PELVIS. 321 

properly, to the very exceptional form in which the entire acetabulum 
is separated from the rest of the os innominatum and displaced inward. 
AVorner seeks further to restrict the term to those cases in which the 
fracture is confined mainly to the acetabulum and its margins, at the 
most breaking the pelvic ring only on the pubic side. 

Typical form. In one or two of the typical class in young patients the 
lines of fracture have apparently followed the conjugal Y-cartilage of the 
acetabulum. The external iliac artery and vein have each been torn once. 

The injury has been caused always by great violence acting upon the 
side of the pelvis and doubtless also on the great trochanter. The 
patient is completely disabled, and it is easy to recognize that the injury 
is extensive and severe. The details may be made out by systematic 
exploration of the accessible portions of the pelvis, including its inner 
face so far as it can be felt through the rectum. Palpation within 
Poupart's ligament discloses the change in the line of the pelvic ring at 
that point and possibly the head of the femur displaced inward. The 
finger in the rectum or vaginia finds the palpable surface swollen and 
tender. The great trochanter is sunken, approximated to the median 
line, to an extent corresponding to the dis- 
placement inward of the head of the femur. FlG - 176. 

Occasionally there has been bleeding from <w_ .. 

the bladder or rectum. ^^WKn 

In the absence of grave associated lesions /^^f%^jY-~^b - ; ^J\ 
the chances of recovery are favorable, under l^^^'m^^Sf^^ ''^M 
immobilization and traction upon the thigh, \\ | -\^§ 

with some use of the limb. ^3|l Irr |u f 

A case showing the possibilities of repair fcfe^^S'TK '-^^w 

was reported by Moore. 1 A man received nJES t$JmB^ 

a severe injury of the hip thought to be a ^^^eiP^^Prl 

fracture of the neck of the femur ; he recov- ^^m^w^\ f. ^ 

ered and was able to work with only a slight l 

limp. At the autopsy several years later Head of the femur driven through 

the injury was found to have been a fracture the acetabulum - 

of the pubis, ilium, and acetabulum with 

deep displacement inward of the head of the femur (Fig. 176). 

In the second form, fracture of the floor of the acetabulum, the force 
has apparently been received only upon the trochanter or perhaps along 
the widely abducted thigh. As above stated, the lesions vary from a 
splintering of the floor with slight displacement to a crush in which 
more than half of the floor with the adjoining margins is split in several 
directions and turned back angularly by the penetrating head of the 
femur. Apparently the pubic portion of the socket is entirely broken 
through in most, if not in all, of these cases, the iliac and ischial portions 
of the socket receiving little or no injury beyond the limits of the floor. 
This readily explains the fact that several patients have been able to 
walk immediately after the receipt of the injury, the weight of the 
body being transmitted through the unbroken ilium. 

1 Moore : Medico-Ckirurgical Transactions, vol. xxxiv. p. 107, 
21 



322 FRACTURES. 

In the slight form, simple splintering of the floor, it is doubtful if 
a diagnosis can be positively made, even with the aid of the ce-rays. 

In the more extensive forms there is loss of function with preserv- 
ation of most of the range on passive motion except in abduction. 
There is slight shortening of the limb, and flattening of the trochanteric 
region in correspondence with the depth to which the head of the femur 
has penetrated and tenderness and fulness within the brim of the pelvis 
over the joint, and possibly tenderness and swelling to be felt through 
the rectum. 

Fig. 177. 





Fracture of the floor of the acetabulum. A, before, B, after reduction. Reduced 
tracing from Wolffs skiagram. 

By forcible traction outward at the upper part of the thigh Wolff 
greatly reduced the displacement in one case (Fig. 177), and got a fairly 
good functional result. In the other cases, in many of which even the 
nature of the injury was not fully recognized at first, the patients re- 
covered with considerable deformity and disability. 

3. TRANSVERSE FRACTURE OF THE SACRUM. 

This rare injury is produced by blows or falls upon the correspond- 
ing region, and appears in all cases to have occupied the lower half of 
the bone and to have been produced by the forcible bending inward of 
its apex. Its direction is practically transverse. Malgaigne has 
reported one case of oblique fracture ; in it the violence was received 
upon the side of the bone, and there were also two incomplete trans- 
verse fractures. 

The usual displacement is an angular one, the coccyx and lower frag- 
ment being drawn forward so that the apex of the angle is directed 
backward at the seat of fracture. The displacement is due in part to 
the fracturing force and in part to the action of the attached muscles. 
In a case that came under my observation at Bellevue Hospital there 
was extensive sloughing over the sacrum and denudation of the bone, 
apparently due to the direct violence that caused the fracture. The 
same complication is mentioned in two of the five cases collected by 
Malgaigne, both terminating fatally. 

The symptoms are : pain at the seat of fracture, both spontaneous and 
provoked by pressure or movements of the trunk, or by the act of defe- 



PLATE XXXIV 




Fracture of Acetabulum and Displacement of Femur Inward 



FRACTURES OF THE PELVIS. '323 

cation, or perhaps by the act of coughing; the displacement if present; 
and abnormal mobility and crepitus recognized by grasping the lower 
fragment between the thumb and a finger introduced into the rectum. 

Agnew 1 says "there will probably be present paralysis of the blad- 
der and rectum, both of these organs receiving nerves from the sacral 
plexus," and Lossen 2 says that when there is complete displacement of 
the fragment paralysis of the lower extremities, bladder, and rectum 
is never absent, but neither author quotes any cases in support of the 
statement. In the one case that has come under my own observation, 
there was almost complete paralysis of the lower limbs, bladder, and 
rectum, which nine months after the accident had been recovered from 
in great part. 

In Bermond's case, quoted by Malgaigne, the fracture was near the 
coccyx, and the lower fragment was displaced so far forward that the 
finger could not be passed into the rectum until after a female catheter 
had been introduced as a guide. The pain was extreme, was relieved 
by the reduction of the displacement, and returned as soon as the finger 
was withdrawn. 

Treatment. Unless there is marked displacement, no treatment is 
required beyond the use of pads or rings to relieve the lower fragment 
from pressure. In some cases the surgeons have sought to diminish 
the pressure by flexing the thighs and supporting them upon pillows 
piled up under the knees. 

In two cases the surgeon has tried to make direct pressure upon the 
lower fragment by dressings introduced into the rectum. Judes, quoted 
by Malgaigne, used a cylinder of wood five inches long and one inch in 
diameter with graduated compresses outside and a T-bandage to sup- 
port the whole. Bermond filled the rectum with a bag of lint, which 
soothed the patient's pain but had to be removed on the following day 
to allow the bowels to be emptied. He then used a shirted canula 
through which the gas and feces could be passed at will while the rec- 
tum was kept distended by the tampon. It was removed temporarily 
on the seventh day, and finally on the nineteenth, when abnormal 
mobility could no longer be detected. 

4. FRACTURE OF THE COCCYX. 

There is but little definite knowledge concerning this lesion. The 
first mention of it appears to be that of Cloquet in the statement that 
when in old people union has taken place between the different por- 
tions of the coccyx, and between it and the sacrum, the coccyx might 
be broken by a fall upon the buttocks or, as in a case which he had 
seen, by a kick upon the same part. He refers also to another ease in 
which caries of the coccyx followed its fracture, but, as Malgaigne 
says, it does not appear that Cloquet verified the. fracture. Within a 
few years several cases have been published, and it is furthermore pos- 
sible that some of the cases described as dislocations of the eoccyx or 
coccygodynia may have been fractures. None of the cases of fracture 

1 Agnew: Surgery, p. 922. 2 Lossen: Deutsche Chirurgie, Lief, 65, p. 7, 



824 FRACTURES. 

mentioned has been described with any details, and there is, there- 
fore, nothing to be said except that the diagnosis must be made as 
after fracture of the sacrum, and that probably no treatment would be re- 
quired except to reduce displacement. (See Dislocations of the Coccyx.) 
Jolly 1 reported a unique case of escape of the lower segment jof the 
coccyx through the anus ten days after delivery, the bone apparently 
having been broken at that time. 

5. FRACTURE OF THE ILIUM. 

Fractures of the expanded upper portion of the ilium are compara- 
tively frequent and vary widely in their position and extent; the 
more extensive ones pass transversely or obliquely from before back- 
ward at some distance below the crest and are associated sometimes 
with vertical lines which divide the upper fragment into two or more 
portions. Malgaigne says that when the fracture lies near the crest it 
begins commonly at a triangular prominence on the crest near its 
middle, and runs thence backward or forward, or in both directions, 
following a curved line the concavity of which is directed upward. 
The fracture may be limited to a small portion of the rim of the bone, 
as the anterior superior spinous process or the outer lip of the crest. 
In a unique case observed by Hamilton, the posterior superior spinous 
process was broken off by a fall upon the back ; and Riedinger and 
Linhart 2 have shown experimentally that the anterior inferior spinous 
process can be torn off by putting the Y-ligament of the hip-joint 
upon the stretch. In a case reported in the Bulletins de la Societe 
Anatomique, 1867, p. 283, the anterior superior and inferior spinous 
processes were broken off while still in the condition of epiphyses by 
the passage of a wagon. The patient was fifteen years old. 

The displacement is usually slightly outward, and forward when the 
line of fracture is below the anterior superior spine. Fragments of 
the crest alone may be markedly displaced upward, and after fracture of 
the anterior superior spine the fragment may be displaced downward. 

Cause. The cause has heretofore been thought to be direct violence 
exclusively, but Hamilton reported a case of fracture by muscular 
action separating a piece of the crest three inches long and including 
the anterior superior spinous process. Nickerson 3 has reported 
another of the anterior superior spine with abstracts of four additional 
cases, and Whitelocke 4 two others in lads eighteen and nineteen years 
old while running, and Albertin 5 and Reverdin 6 similar ones. 

Symptoms. The usual signs of pain and swelling are increased by 
the associated bruising of the overlying soft parts ; abnormal mobility 
and crepitus can be felt on manipulation at times, but their manifesta- 
tion depends upon the position of the fragment, the posture of the 
patient, and the contraction or relaxation of the muscles. In a case 
under my care where a large fragment composed of the anterior half 

i Jolly : Medical Record, Dec. 17, 1887. 

2 Linhart : Langenbeck's Archiv. vol. xx. p. 451. 

:! Nickerson : Deutsche med. Wochenschrift, March 6, 1890. 

* Whitelocke : Lancet, November 25, 1893. 

5 Albertin : La Province Medicale, 1887, p. 741. 

e Reverdin : Centralblatt fur Chirurgie. 1900, p. 352. 



FRACTURES OF THE PELVIS. 325 

of the crest and the adjoining bone had been broken off by a fall, 
mobility and crepitus would at times disappear entirely, apparently in 
consequence of slight changes in the position of the fragment. In 
seeking for mobility and crepitus the abdominal muscles should be 
relaxed by bending the body forward and to one side, and the thighs 
should be flexed on the pelvis. 

The patient is usually unable to walk, because of pain or of the 
sense of a lack of support. 

Course. The course is usually a simple one, and the patients are 
sometimes able to leave their beds in two or three weeks. In some 
very exceptional cases where the violence has been extreme fatal 
injury has been done to the viscera, such as perforation of the intes- 
tines by a splinter or laceration of the iliac veins ; and suppuration 
has sometimes taken place. 

Treatment. The treatment is simple, rest in bed in the position 
which gives most ease and is most favorable to the relaxation of the 
muscles which would be likely to cause displacement. The attempts 
that have been made in the few recorded cases of fracture of the 
spinous processes to keep them in place by pressure with pads and 
bandages have been entirely unsuccessful. 

6. FRACTURE OF THE ISCHIUM. 

This is one of the rarest of the fractures of the pelvis. Malgaigne 
collected only six cases, and the list has not been since increased by 
any reported in detail. In some of the cases almost the entire ischium 
was broken off, in others only the tuberosity. Experiment indicates 
that the fracture may pass into the cotyloid cavity. In three of Mal- 
gaigne's cases the cause was a fall upon the buttocks, the fourth was a 
gunshot fracture, the fifth was caused by an explosion, and the sixth 
was in a woman who had recovered from a double vertical fracture 
of the pelvic ring with a displacement that narrowed the inferior strait 
so much that two years afterward delivery could be effected only with 
the aid of forceps, and the ischium was broken in the effort. In two 
of the cases the fracture was comminuted, and in one of them also 
compound, in the other the scrotum was lacerated and the urethra 
torn, presumably by violence received at the same time upon the peri- 
neum and not by displacement of the bone. In the simple cases 
there was little or no displacement ; in the gunshot fracture the frag- 
ment was displaced downward more than two inches by the contraction 
of the hamstring muscles. The displacement persisted, but does not 
appear to have interfered materially with the movements of the limb. 
All except the sixth recovered. 

Mobility and crepitus can be recognized by manipulation of the 
bone, preferably with the finger in the rectum or vagina. The severity 
of the pain depends upon the violence and the associated injuries and 
makes it difficult for the patient to walk. 

No treatment is required except rest in bed with pillows or air- 
cushions so arranged as to prevent pressure upon the broken bone. If 



326 FRACTURES. 

the patient lies upon the side the knees may be kept flexed to relax 
the muscles which are attached to the ischium. 

7. FRACTURE OF THE PUBIS. 

In almost all cases of its fracture the pubis is so broken that the 
continuity of the pelvic ring is destroyed ; the cases in which only one 
ramus has been broken or iu which a lateral fragment has been broken 
oif are extremely rare, and consequently there is but little to be added 
to what has been already said in the first portion of this chapter. The 
only cases of this limited fracture of which I have any knowledge are 
one reported by Nivet and one by Cappelletti. In Nivet's ! case, the 
account of which is not quite clear, there appears to have been a double 
fracture of the descending ramus, the intermediate piece was displaced 
forward and had torn the skin of the groin. In Cappelletti's 2 case a 
man jumped from a carriage, alighting upon his feet with one limb 
widely abducted. Six months afterward there was still some swelling 
at the anterior superior part of the right thigh, and a fragment of bone 
about two and a half inches long, and as large as the finger could be 
felt there. Cappelletti was convinced that this fragment was a portion 
of the descending branch of the pubis and the ascending branch of the 
ischium detached by muscular action. The pelvis appeared to be defec- 
tive anteriorly at the point corresponding to the supposed original seat 
of the fragment, there was acute pain on pressure at the swelling and 
at the tuberosity of the ischium, the patient walked limping and with 
pain, and the pain was increased by abduction of the limb. 

8. FRACTURE OF THE RIM OF THE ACETABULUM. 

This is a lesion which sometimes accompanies partial or complete 
dislocation of the femur upon the pelvis. 

The upper and posterior portion of the rim is the part most fre- 
quently broken, and the accompanying dislocation is commonly back- 
ward. In one of M'Tyer's cases 3 there were two fragments, and in 
Maisonneuve's case three, but in this latter the fracture was much 
more extensive. In another case (IVFTyer) the fracture had united 
with but slight displacement, and the ligamentum teres was untorn. 

The symptoms, when the case first comes under observation, are those 
of simple dislocation backward, and the complication of fracture is 
recognizable only by slight crepitus felt on manipulation or during 
reduction and by the easy recurrence of the dislocation after reduction. 
Sometimes the head of the bone slips out of its socket again as soon as 
the traction ceases, in other cases only after the lapse of a few hours or 
on movement of the limb or body. 

Malgaigne calls attention to the necessity of making sure of the 
existence of a dislocation, and of not depending for the diagnosis solely 
upon crepitus and easy recurrence of the displacement, signs which 

1 Nivet : Bull, de la Societe Anatomique, 1837, p. 194. 

2 Cappelletti : Banking's Abstract, 1848, vol. viii. p. 91. 

3 M'Tyer : Glasgow Medical Journal, 1830. 



FRACTURES OF THE PEL VIS. 327 

may accompany fracture of the neck of the femur. The prominent 
distinction between dislocation backward and fracture of the neck of 
the femur is in the position of the limb, which is flexed upon the 
pelvis and rotated inward in the former, and usually straight and 
rotated outward in the latter, but this alone should not be depended 
upon, the position of the head of the bone should be made out. 

The treatment should be directed to the prevention of a recurrence 
of the dislocation after its reduction. Continuous traction gave me a 
good result in one case, but theoretically abduction and extension of the 
limb should be maintained, as the attitude most opposed to recurrence. 



CHAPTEK XXIII. 

FRACTURES OF THE FEMUR. 

Fractures of the upper end : Head, neck, separation of epiphysis, through the 
trochanter and neck, great trochanter, trochanter minor. Of the shaft. Of 
the lower end : Intercondyloid, separation of epiphysis, either condyle. 

The table in Chapter I. shows 540 fractures of the femur in a total 
of 14,566 cases (3.7 per cent.). Those of the London Hospital for 
twenty-six years show 3243 in a total of 51,938, about 6 per cent. 
The Berlin and Halle records, quoted by Gurlt, show in totals of 232 
and 97 fractures of the thigh, 76 and 21 of the neck of the bone respec- 
tively. The records of Belle vue Hospital for nine years, collated by 
Dr. F. E. Hyde, 1 contained 302 cases of fracture of the thigh, in which 
the position of the fracture was stated, divided as follows: neck 61, 
upper third (exclusive of neck) 34, middle third 169, lower third 31, 
of which 7 were of the condyles. Of 236 fractures of the thigh recorded 
by Hamilton, 84 were of the neck, 30 of the upper third, 86 of the 
middle third, and 36 of the lower third. 

Malgaigne's analysis of 311 fractures (104 of the neck, 207 of the 
shaft) according to age and sex is as follows : 

Fractures of the Shaft. 

Age. Male. Female. 

2 to 20 years 35 12 

20 " 40 " 47 6 

40 " 60 " . . . . . . . 43 15 

60 " 80 " .20 29 



145 



62 = 207 



Fractures of the Neck. 

Age. Male. Female. 

4 to 50 vears 9 5 

50 " 60 * " . . . . . . .9 10 

Above 60 " 30 41 



48 



56 = 104 



Recent observations indicate that the proportion in this table of 
fractures of the neck in early life is too low, the cases probably having 
passed unrecognized. See below. 



328 



Hyde : New York Medical Record, 1875. 



FRACTURES OF THE FEMUR. 329 

1. FRACTURES AT THE UPPER END OF THE FEMUR. 

In this class are included fractures of the head, of the neck of the 
femur, separation of the epiphysis, fractures of the great trochanter 
and separation of its epiphysis, fractures through the trochanter, and 
fracture of the trochanter minor. 

A. Fractures of the Head of the Femur. 

The only reported instances of this very rare injury have been 
obtained in cases in which there was also dislocation backward of the 
head of the bone. Riedel (quoted by HofFa) reported one, a boy fifteen 
years old who had been run over by a heavy wagon. The dislocated 
head was split by a line of fracture which also traversed the neck lon- 
gitudinally, and the posterior portion of the rim of the acetabulum was 
crushed. The upper outer fragment and the trochanter were removed ; 
the rest of the head was returned to the socket. Healing with anchy- 
losis. 

Braun l reported a similar case, the line of fracture running from the 
insertion of the ligamentum teres to the attachment of the capsule. 

I showed to the New York Surgical Society 2 a specimen showing a 
crush of the anterior portion of the head one inch long, half an inch 
wide, and one-eighth inch deep, caused evidently by impact against an 
exostosis situated close behind the rim of the acetabulum ; the injury 
closely resembled that occasionally produced in the head of the humerus 
in an anterior dislocation by impact against the edge of the glenoid 
fossa. 

B. Fracture of the Neck of the Femur. 

The opinion long held that this was essentially an injury of advanced 
middle life and old age has been modified by recent observations made 
with the aid of the x-rays. Whitman, 3 Hoifa, 4 Haldenwang, 5 and 
others have shown that it is quite common in the young, having heretofore 
been largely overlooked because of the comparative mildness of the 
early symptoms. The earlier investigators thought most of the cases 
were separation of the epiphysis (Hess 36 out of 46 cases), but that 
view now appears to be incorrect. Haldenwang collected 25 cases of 
fracture between the ages of one and eighteen years and only "2 of separa- 
tion. Of the 25, 15 were females ; 7 were ten years of age or younger, 
and 17 between ten and eighteen years. In the majority the fracture 
was at the base of the neck, most of the remainder in the middle third, 
and only one or two close to the head. In only 6 was the injury 
promptly recognized as a fracture ; in the others only after the lapse of 
weeks or months by the .r-rays or in the course of an operation. Many 

1 Braun: Arch, fur klin. Chir., July, 15, 1892. 

2 Stimson : New York Medical Journal, August, 2SS9, p. 163. 

3 Whitman : Annals of Surgery, June, 1897, and February, 1900. 

4 Hoffa : Zeitschrift, fiir Orthop. Chir. , vol. xi. part 3. 

5 Haldenwang : Beitrage zur klin. Chir., 1908, vol. 57, p. SI. 



330 FRACTURES. 

of the patients were able to go about from the first, but with consider- 
able difficulty and pain. All that I have seen have been fractures at 
or close to the base of the neck ; one of them, a boy fifteen years old, 
who received his injury by slipping and falling on the sidewalk, walked 
unaided to the hospital, a distance of four hundred yards (Plate 
XXXV). The cause of this partial maintenance of function is thought 
to be close impaction in some, infraction rather than complete fracture 
in others, and the thickness and toughness of the periosteum. The 
causative violence in the young is usually slight, and in some the ab- 
sence of history of violence suggests a preliminary rachitic softening. 

In fractures in robust patients in middle life the violence is usually 
great. 

In the old the injury is much more common in women than in men. 

It is often produced, too, by slight causes, such as a mistep, a stum- 
ble, a fall upon the knee or hip, and these two facts taken together 
indicate senile change in the bone as a markedly predisposing cause. 
Examination of the thigh bones of old people, those that have been 
broken and those that have not, bears out this indication, for it shows 
all the parts of the bone much rarefied, with thinning of the cortical 
shell and enlargement of the meshes of the spongy tissue. 

Another reason for the greater frequency of these fractures in the 
old has been sought in a change alleged to take place in the angle at 
which the neck joins the shaft. It has been asserted that as the indi- 
vidual grows older this angle approaches a right angle, a position that 
would favor fracture, but examination has proved this not to be the 
rule. Rodet 1 found the average angle in the child and adult 131 
degrees, and in the old 128 degrees, a difference too small to deserve 
attention, especially since the limits between which the angle ranges 
normally are Avide, 121 degrees and 144 degrees according to the same 
author. Similar findings have been published by others ; on the other 
hand, Lauenstein found the angle changed. 

Other points in the connection between the neck and the shaft require 
mention because of their influence in the production of the fracture and 
m the character of the displacement. The antero-posterior diameter 
of the neck is much smaller than that of the shaft, and the two are so 
joined that a large part of the great trochanter lies behind the posterior 
wall of the neck, and, as shown by Prof. Bigelow, 2 it is traversed in 
part by a prolongation of the posterior wall of the neck (Fig. 178). 
This prolongation which Bigelow calls the true neck constitutes a ver- 
tical septum, " a thin dense plate of bone continuous with the back of 
the neck, and reinforcing it, plunging beneath the intertrochanteric 
ridge in an endeavor to reach the opposite and outer side of the shaft. 
At its lower extremity it curves a little forward so as to take its origin, 
when on a level with the lesser trochanter, from the centre instead of 
the back of the cylindrical cavity." The posterior part of the tro- 
chanter is therefore only an apophysis attached to the shaft for the 
insertion of the rotator muscles, and the mechanical function of the 

1 Rodet : These de Paris, 1844, quoted by Tillaux and others. 

2 Bigelow : The Hip, p. 121. 



FRACTURES OF THE FEMUR. 



Pig. 178. 



shaft and neck with reference to the resistance to strain is practically 
independent of it. The rarefying senile change affects this septum and 
may remove it so completely that it cannot be distinguished from the 
surrounding cancellous tissue. 

The capsule is usually attached to the femur in front along the spiral 
line, above to the neck a little short of its junction with the trochanter, 
behind to the neck itself about half an inch from the intertrochanteric 
line, and below to the upper part of the 
lesser trochanter. In front and below, 
therefore, the neck lies entirely within 
the capsule, while above and behind its 
outer third or fourth part is external to it. 
These limits vary somewhat in different 
individuals. The synovial membrane does 
not follow the capsule closely to its inser- 
tion, but it is reflected early from it to the 
neck, leaving a strip of the latter between 
the points where it joins the capsule and 
the synovial membrane which although 
intracapsular is yet extra-articular. The 
periosteum is thick, and contains, especially 
in its upper portion, numerous bloodvessels 
which enter the head and neck by the large 
foramina found there. Of these vessels, 
one in particular, a branch of the internal 
circumflex artery, is of considerable size, 
runs along the upper portion of the neck 
and enters the head. Wilkinson King 1 
long ago called attention to the fact that 
this portion of the periosteum is frequently 
left untorn in fracture of the narrow part 
of the neck, and suggested that this arte- 
rial branch might preserve the vitality of 
the head of the bone under such circum- 
stances. Later observations indicate that 
the vitality is preserved, and presumably 
by this agency, much more frequently than has long been supposed. 

The division into intracapsular and extracapsular fractures, so long 
current and still so widely used, had its origin in important pathological 
differences, but it has proved unsatisfactory and misleading, partly 
because the two terms do not properly express these differences and, 
consequently, leave a large group — the " mixed'" fractures, those in 
which the line of fracture lies partly within and partly without the 
capsule — to be classed sometimes with one and sometimes with the 
other, and partly because the associated theory that repair was impos- 
sible after intracapsular fracture, although subsequently abandoned by 




Neck of femur. (Bigelow.) 



King : Guy's Hospital Reports, 1S44, p. 347. 



332 FRACTURES. 

its author, Sir Astley Cooper, and many times disproved, has clung to 
it in many minds until the present time. The breaking away from 
this classification which has appeared in so many of the systematic 
writings of the last thirty years is largely due to the late Professor 
Bigelow who suggested the terms fracture at the narrow 'part of the neck 
and fracture at the base of the neck. These have the disadvantage of 
being rather cumbrous and of unduly limiting the seat of fracture in 
the former, for which, therefore, it seems to me advisable to substitute 
the term fracture through the neck. An alternative measure recom- 
mended by some (most recently Sir William Stokes ] ), of fracture of the 
neck for the former and at the base of the neck for the latter, is open to 
the objection that the first is also habitually used for the injury as a 
whole and is, therefore, liable to be misunderstood when used as mean- 
ing either more or less than was intended. Kocher's 2 recently proposed 
fractura subcapitalis for the first finds some favor, but fractura inter- 
trochanterica and fractura pertrochanterica for the latter do not seem 
likely to be acceptable. 

The importance of the distinction in prognosis and treatment is cer- 
tainly not so great as has been alleged, nor is the presence or absence 
of so-called impaction. The capital point in prognosis — the degree of 
vitality of the upper fragment — apparently depends not upon impac- 
tion nor upon the situation of the fracture, but upon the preservation 
of the vascular supply furnished by the vessels which approach the bone 
near the insertion of the capsule and run to the head in the thick peri- 
osteum of the neck. In fractures at the base of the neck these vessels 
are not much injured, and in fractures at the narrow part of the neck 
the continuity of the periosteum and the included vessels appears to be 
sufficiently preserved in many, perhaps most, cases to maintain the 
vitality of the fragment. The number of specimens of bony union 
after undoubted fracture at the narrow part of the neck is not only 
large enough amply to demonstrate the possibility of such repair, but 
also, in comparison with those of failure of union and in connection 
with clinical results, to indicate that such union is probably common 
under appropriate treatment and in the absence of injudicious move- 
ments at first which may destroy the connection left by the fracture. 
Moreover, it is clinically impossible positively to distinguish between 
many of these fractures at the narrow part of the neck and those at 
the base in which there is little or no injury to the adjoining part of 
the shaft and its periosteum. 

It therefore seems to me unwise to make a sharp distinction between 
the two forms and to urge, as some do, that fractures of the narrow part 
of the neck, or intracapsular, should be deemed from the first inca- 
pable of union and treated accordingly. I think, on the contrarv, that 
union should be sought in all cases and almost always by the same 
methods and that the diagnostic differentiation at the outset, therefore, 
is rarely of practical importance in treatment, although affecting prog- 
nosis. Although the distinction must be preserved in the description 
of the forms of fracture (I shall use the names fracture through the 

1 Stokes : British Medical Journal, October 12, 1895. 

2 Kocher : Praktisch wichtiger Frakturformen, 1896. 



FRACTURES OF THE FEMUR. 333 

neck, or subcapital, and, fractures at the base of the neck) the .sections 
on symptoms and treatment will treat of them jointly. 

In order to get an indication of the relative frequency of the two 
forms I examined the .r-ray plates^of 33 successive patients at the New 
York Hospital ; 27 were at the base of the neck and 6 at various points 
in the neck ; one of the latter was quite close to the base. An exami- 
nation of such few plates at Bellevue Hospital as were clear enough to 
give positive information, gave 21 at the base and 8 at the neck. 

Causes. 

An important predisposing cause has been mentioned, the senile 
rarefaction which begins usually after the fiftieth year and is more 
marked in females than in males. 

The common cause in the old is a fall to the ground while walking ; 
occasionally a stumble or a misstep with an effort to avoid a fall, or the 
jar occasioned by stepping down to a slightly lower level than was 
anticipated. 1 In the young the cause is also usually moderate violence, 
but in robust adults it is usually much greater violence, as in a fall 
from a height, but reports of cases are accumulating which indicate that 
a perhaps notable proportion of injuries caused by moderate violence 
and deemed sprains or contusions of the hip are fractures, incomplete 
or without separation. 

It is probable that the strain exerted through the ligaments in ex- 
treme positions of the limb is a more frequent cause of fracture than 
is generally supposed, and that the fall is sometimes the consequence 
rather than the cause. A number of cases are on record in which the 
bone has been broken in this manner, and by efforts so slight in some 
of them that they might easily have been overlooked if a fall had been 
associated with them, and experiment upon the cadaver confirms the 
opinion. The efforts which have been made to explain different varie- 
ties of fracture by differences in the direction of the blow or in the 
point at which it has been received have not been satisfactory either as 
a demonstration or as an aid in diagnosis. Few patients are able to 
tell exactly how they have fallen, and even if they could do so there 
would still be enough uncertainty concerning the extent to which the 
position of the limb had intervened to vitiate the conclusions that 
might otherwise be drawn from the circumstances of the fall. On 
the cadaver the bone can be broken at the narrow part of the 
neck by a blow on its head, or on the knee when the limb is 
somewhat abducted, and at the base of the neck by a blow upon 
the trochanter, if the cadaver is that of an old person ; and it is 
comparatively easy to break the bone in the old, either at the base 
or at the narrow part of the neck, by abduction, adduction, or 
rotation. In some of the fractures produced by strain through the 

1 For illustrative cases of fracture by slight causes and of experimental fracture 
see previous editions and Cooper, loc. cit., pp. 155 and 157; Earle, Practical Obs, on 
Surg., 1822, p. 20; Malgaigne, loc. cit., vol. i. p. 666; Linhart, Deutsche Gesellsehaft 
fur Chir., 1875; Riedinger, Centralblatt fur Chir., 1875. p. S17; Stetter, Idem, 1ST7. p. 
561. 



334 FRACTURES. 

iliofemoral ligament (by hyperexteusion and abduction) the break 
takes place outside the attachment of the ligament along the spiral 
line and the ligament remains attached to the upper fragment. In 
others with apparently the same mode of production the fracture is 
through the narrow part of the neck. 

Muscular action may be a cause by producing a forced position of the 
limb in which the capsule, and especially the Y-ligament, is put upon 
the stretch, the mechanism then being the same as when the corre- 
sponding position is given by an external force. 

Pathology. 

The line of fracture may lie at any point between the junction 
of the head and neck and the base of the neck, and in the latter 
case it may be associated with more or less splitting of the trochanter 
and adjoining shaft, or it may pass (rarely) from the lower part of 
the junction of the neck and shaft transversely to the outer side. 
Fractures at a somewhat lower level, below the trochanter minor, will 
be considered among fractures of the shaft. There are, therefore, to be 
considered here fractures through the neck, fractures at the base of the 
neck with or without splitting of the trochanter, separation of the 
epiphysis, and fracture through the trochanter. 

(a) Fractures Through the Neck. (Intracapsular fracture, subcapital 
fracture ) The frequency of these fractures has been thought to in- 
crease with advancing age after sixty years, but the facts upon which 
the opinion rests are mainly clinical and, therefore, not entirely trust- 
worthy. I am convinced, by clinical evidence as well as by the statis- 
tics given on the preceding page that, except perhaps in the young, this 
form is much less frequent than fracture at the base. 

The line of fracture may be transverse, oblique, or irregular ; it may 
lie close to the head or at some distance from it, or may (rarely) pass 
slightly into the head itself. In a few old specimens the appearance 
suggests that the line of fracture was incomplete on one side, but as 
the head in such cases shows a well-marked angular displacement it is 
probable that the fracture was complete with bending but no other 
displacement at the apparently continuous portion and crushing else- 
where. The surface of fracture is frequently irregular, but sometimes 
uniform and sometimes smooth or irregular on the side of the head 
while the neck on the other side is crushed or comminuted (Fig. 179). 

Angular deviation at the fracture is the rule, the apex of the angle 
being usually directed forward and upward, and is habitually effected 
by crushing of the bone or by penetration of one fragment into the 
other. This penetration or impaction is rarely more than a simple 
interlocking of the irregularities of the surface, although Bigelow l 
reported one in which considerable force was required to separate the 
fragments ; possibly the fixation was due to incompleteness of the 
primary separation at some point on the periphery, as in the so-called 
" incomplete " fractures (Fig. 180). 

1 Bigelow : Loc. cit., p. 131. 



FRACTURES OF THE FEMUR. 335 

The periosteum of the neck appears usually to remain untorn over 
a portion of the periphery, and may even be complete, as in cases 
reported by Mayor 1 and Stanley. 2 In one of my specimens the 
untorn portion is nearly an inch wide and is situated at the lower and 
posterior portion of the neck ; in another it was broadly preserved in 
three bands ; in other reported cases it has been behind, behind and 
above, and above and in front. If the primary displacement is great, 
or if it is increased by an attempt to bear the weight upon the limb, 
the rupture may be or may become complete and the fragments may 
be widely separated, both of which circumstances would seriously affect 
the prognosis ; under similar circumstances the capsule may be torn. 



Fig. 179. 



Fig. 180. 





Fracture through the neck of the femur. (F. sub- 
capital. ) (Kocher.) 



So-called "incomplete" fracture of the 
neck of the femur. (Konig.) 



(b) Separation of the epiphysis has been demonstrated by specimen 
in a few cases and suspected in a number in which fracture of the neck 
has occurred in the young, but there is reason to believe that it is rarer 
even than fracture at the corresponding age. The conjugal cartilage 
immediately adjoins the head, and bony union takes place between the 
seventeenth and twenty-first years. The first case verified by direct 
examination was reported by Bousseau. 3 The patient was fifteen years 
old, and was run over by a wagon. The symptoms were shortening, 
eversion, and inability to move the limb. The patient died in a few 
hours. The separation was complete along the epiphyseal line, and 
the head was attached to the neck only by a strip of periosteum two 

1 Mayor: Gazette MSdicale, L834, p. 612. 

2 Stanley: Medico-Chirurgica! Transactions, 1825, vol. xiii. p. 511. 

3 Bousseau : Bulletins de la Sooieto Anatomique, istrr. p. 283. 



336 



FRACTURES. 



Fig. 181. 



millimetres wide. The periosteum was stripped up on the inner and 
lower part of the neck, and the capsule was torn at its inner portion. 

Kocher l reports two. The first is that 
of a girl sixteen years old, who fell while 
walking and struck upon her right tro- 
chanter. On the theory that if the in- 
jury, as supposed, was a fracture through 
the neck (or separation of the epiphysis) 
repair was impossible, an operation was 
done three weeks later for the removal of 
the upper fragment. A fracture, hidden 
by the untorn periosteum, was found along 
the epiphyseal line, with penetration of 
the posterior part of the neck into the 
head ; the latter was removed ; recovery 
with anchylosis. 

The second case Was that of a girl, 
who, when ten years old, fell from a 
height ; she rose and walked a short dis- 
tance, was then unable to use the limb 
because of pain, and was taken to a hos- 
pital. After apparent recovery she 
walked w T ith a limp which increased as 
time passed. Four years after the acci- 
dent Kocher found shortening of three 
centimetres, outward rotation, and marked 
diminution, active and passive, of motion 
in the hip-joint. The condition found at 
the operation is shown in Fig. 182; the 
head was so tightly fixed in the acetabulum that it was removed with 
difficulty ; the neck was bent sharply downward with an irregular, 




Fracture through the neck in a boy- 
eight years old. (Bolton.) 



Fig. 182. 




Separation of the epiphysis ; old. (Kocher 



knobbed end covered with fibro-cartilage ; the end was placed in the 

1 Kocher : Praktisch wichtiger Frakturformen, 1896, pp. 23S and 243. 



FRACTURES OF THE FEMUR. 



337 

The 



acetabulum and the limb fixed in abduction and inward rotation 
history ends with the recovery from the operation. 

Poland l reports a personal case verified by operation and quotes 
two others, and Whitman 2 reports one in which the injury was 
caused by forcible abduction of the thigh in a lad sixteen years old, 



Fig. 183. 




Impacted fracture at the base of the cervix femoris, with bending of the head backward. 

(Bigelow.) 

the diagnosis being confirmed by a skiagram taken three weeks after 
the accident. He thinks the separation is often only partial, the 
symptoms at first being a slight limp with some stiffness and pain, 
and later, after some slight violence, those of fracture. In two cases 
he corrected the displacement through an anterior incision. Ram- 
stedt 3 thinks that nearly all injuries of the neck of the femur in 
patients less than eighteen years old are separations of the epiphysis 
and that coxa vara is a frequent result. 

(c) Fractures at the Base of the Neck. (Extracapsular and " mixed " 
fractures.) The line of fracture follows ordinarily the junction of the 
neck and shaft quite closely — that is, it coincides with the spiral line in 
front- and the intertrochanteric line behind as they pass between the 
great and lesser trochanters. It may extend downward and detach the 

1 Poland: "Traumatic Separation of the Epiphyses," p. 628. 

2 Whitman : Annals of Surgery, February, 1900, p. 151. See also Med. News, Septem- 
ber 24, 1904. 

3 Ramstedt: Arch, fiir klin. Chir., vol. I x i. part 3. 
22 



338 



FRACTURES. 



Fig. 184. 



Fig. 185. 





Impacted fracture of the neck of the femur 

without splintering. Vertical section. 



Repair after fracture of the neck of the femur. 

(LOSSEN.) 



lesser trochanter from the shaft, leaving it attached to the neck, or go 
even lower and separate a part of the shaft. At its upper part it may 



Fig. 186. 



Fig. 187. 





Comminuted fracture of the neck of the femur. 
Anterior aspect. 



Fracture of the neck of the femur with 
splitting of the great trochanter. 



deflect to either side, crossing the outer part of the neck or traversing 
the great trochanter, in the latter case passing quite beyond the limits 
of the neck. 



FRACTURES OF THE FEMUR. 



In the majority of cases other lines of fracture traverse one or both 
trochanters, splitting off one or two pieces, usually from the posterior 
surface of the great trochanter, or comminuting it completely. Mal- 
gaigne thought that simple fracture, division into only two fragments. 
was exceedingly rare ; the only case of which he knew, excluding two 



Fig. 188. 



Fig. 189. 





Fig. 190. 



Fig. 191. 




Figs. 183 186.— z-ray tracings of fracture of the neck of the femur. 



in which the fracture crossed the trochanter horizontally, was one 
described by R. W. Smith, 1 and, as even in this two fragments are 
broken oif the trochanter behind, it is evident that he believed consid- 
erable comminution to be the rule. Hamilton refers to two similar 
specimens, one in Dr. Mutter's, the other in Dr. NeilPs collection : in 
one of my own specimens there was no splintering, and in another the 
1 R. W. Smith : Loc. cit., ease 34, 



340 



FRACTURES. 



fracture was almost identical with the one quoted by Malgaigne from 
Smith. 

The common fracture is that in which the neck is bent backward 
with crushing of the posterior part or penetration of the neck 
into the trochanter. Prof. Bigelow l directed especial attention to this 
bending backward and impaction (Fig. 183) as the important features 
of the most common form of fracture in this region, the symptoms of 
which are pain and tenderness, disability, shortening and eversion, how- 
ever slight, absence of crepitus, and rotation of the trochanter about 
the head of the bone as a centre, and he described the displacement as 
a rotation of the head and neck backward and downward upon the 





Fig. 192. 










Wet ■■» * 1«»^ 


BC 19 


inSI 


I 


: -^v ] 


r--;\ 




Sk 


i -- - 




Hfo ' .• 





Comminuted fracture at the base of the neck of the femur. 

portion of the anterior wall corresponding to the spiral line uniting the 
trochanters as upon a hinge. This displacement accounts for the ever- 
sion and slight shortening. 

A certain amount of misapprehension has resulted from the use of 
the word impaction. Impaction, in the sense of penetration and fixa- 
tion, is, I think, uncommon ; while crushing, with or without penetra- 
tion or much splitting of the trochanter, is the rule. The penetration 
or crushing may be limited to the posterior part (this, as has been said, 
is the most common condition), or the neck may turn upon its upper 
portion, making that the hinge, and sink its anterior, posterior, and 
lower walls into the substance of the trochanter, or the neck may be 

1 Bigelow : The Hip, p. 116, and Boston Medical and Surgical Journal, 1875, vol. xcii. 
pp. 1, 29. 



FRACTURES OF THE FEMUR. 



:U 1 



•hange of direction, 



In exceptional cases 



driven bodily into the trochanter without much 
and may even penetrate to the opposite wall, 
the lower fragment may penetrate 
the upper one. 

The splitting of the trochanter 
may be limited to one or two pieces 
broken off its posterior border (Fig. 
18 7), or it may be very general (Fig. 
192). The extent of the splitting 
seems to be independent of the force 
that caused the fracture, extensive 
comminution being sometimes pro- 
duced by a simple fall while walk- 
ing, as in Fig. 186, which is drawn 
from one of my own specimens. Oc- 
casionally the unbroken trochanter 
may be wholly detached from both 
neck and shaft (Fig. 193). 

In a few cases the angular dis- 
placement of the neck has been in 

the opposite direction, so that the limb has been rotated inward instead 
of outward. R. W. Smith 1 describes one such specimen, and Bigelow 2 




Total separation of great trochanter. 
(Frangenheim.) 



Fig. 194. 



Fig. 195. 




Fracture of the neck of the femur in 
abduction. (KOCHER.) 



Fracture of the neck of the femur in adduction 

(KOCHER.) 



another. In a number of ease 
ments were not interlocked. 

1 R. W. Smith: Loc. cit., p. 128. 



inversion lias existed when the frag- 
- Bigelow : Loc. cit., p. L28. 



342 



FM AC WEES. 



The angular displacement of the neck and the form of the fracture 
appear to be connected with the mode of production of the fracture 
and the attitude of the limb at the moment of fracture; thus, if the 
limb is extended and rotated outward or abducted the anterior por- 
tion of the capsule is tense and the posterior portion of the neck is 
driven into the trochanter (Fig. 194); if the limb is strongly adducted 
in deep penetration is found especially at the inferior portion of the 
neck (Fig. 195). 



Pig. 196. 



Fig. 197. 





Pure intracapsular fracture of the neck of the 
femur. Bony union. (Gurlt.) 



Oblique section of the specimen shown 
in Fig. 191. (Gurlt.) 



The capsule is sometimes torn so that the cavity of the joint is 
opened ; the laceration of the periosteum and adjoining soft parts varies 
with the extent of the comminution and crushing. 



Repair. 

The question of the extent to which repair is possible or probable 
after fracture through the neck is important because of its bearing 
upon treatment. If reunion is possible an effort to obtain it should 
be made, in the absence of controlling contraindications ; if it is im- 
possible or even improbable, treatment must be directed to obtaining 
the best functional result compatible with such failure. 

That repair is possible is abundantly proved by specimens, even if 
we disregard those in which any question can be raised as to the charac- 
ter of the injury or the exact situation of the fracture. Such illustrative 
specimens are those of Stanley, 1 Swan, 2 Gurlt, 3 (Figs. 196 and 197). 
Brulatour, 4 Cushing, 5 Humphry, 6 Raven, 7 and Kocher 8 (Fig. 198). 9 

1 Stanley. Medico-Chirurgical Transactions, 1833, vol. xviii. p. 256. 

2 Swan : Quoted by E. W. Smith, Fractures in the Vicinity of Joints, p. 59. 

3 Gurlt: Knochenbruehen, vol. i. p. 308. 

i Brulatour : Medico-Chirurgical Transactions, 1825, vol. xiii. p. 513. 
5 Cushing : Quoted by Bigelow, The Hip, p. 133. 6 Humphry : Lancet, August 2, 1890. 
7 Raven : Ibid., 1887. 8 Kocher : Loc. cit, p. 206. 

9 For other cases and details the reader is referred to the first edition and the bibliog- 
raphy in it, page 499. 



FRACTURES OF THE FEMUR. 



343 



Fig. 198. 



They include patients of ages varying' from eighteen to eighty-one 
years. 

Other specimens show close fibrous union (Figs. 199 and 200); and 
others in which no form of union had taken place show eburnation of 
the head and other changes which 
demonstrate the preservation of its 
vitality. After fibrous union or 
failure of union the capsule usually 
thickens and sometimes becomes 
closely adherent to the periosteum 
lining the neck, thus obliterating 
all the outer portion of the original 
cavity of the joint. This was the 
condition in two cases reported by 
Colles, 1 and there was actually a 
false joint between the fragments, 
the surface of the lower one being 
hollowed out to receive the upper. 
The process of repair has been 
minutely studied by Frangenheim. 2 
He found that the periosteum of the 
neck forms little or no callus, so that 
union after subcapital fracture must 
be effected, if at all, by the spongy 
tissue. Fibrous union may be close 
and firm. Absorption of the neck 
may take place very promptly ; he 
thought it occurred only after sub- 
capital fracture. Occasionally the 
opposing surfaces of head and neck 
become eburnated and a nearthrosis 
is formed. He quotes with approval Gurlt's statement that fracture of 
the neck of the femur is the slowest of all fractures to heal, and gives 
a case of deeply impacted fracture at the base, in which union after 
eight and one-half months was still fibrous, although so firm that it 
was thought to be bony before the specimen had been sawn. 

Some specimens of failure of union show entire disappearance of the 
neck, the head remaining in the acetabulum and presenting a smooth 
uniform surface ; there is a similar smooth surface on the mesial aspect 
of the shaft at the place corresponding to the base of the neck (Fig. 
201). The situation of the fracture in such cases cannot be positively 
known ; the neck has disappeared by crushing and rarefaction, and this 
presumably can happen after either form of fracture. 

Some specimens with union show an almost equal absence of the 
neck ; in some, as shown in Fig. 185, the neck still exists, but has 
been driven into the trochanter; in others it has disappeared in great 
part, presumably by crushing and rarefactive osteitis, and it is difficult 
or impossible exactly to determine the primary position of the fracture. 




Bony union after fracture through the neck, 
(F. subcapitalis.) (Kocher.) 



'Colics: Dublin Hospital Reports, vol. ii. p. :YM. 

2 Frangenheim : Deutsche Zeitschrift fur Chir.. 1906. vol 



p. 401. 



344 



FRACTURES. 



These latter specimens are of special interest because they have been 
used to support the theory that interstitial absorption of the neck may 



Fig. 199. 



Fig. 200. 




Fracture within the capsule ; fibrous union. 
(Smith.) 




Fracture within the capsule. Close fibrous union. 



be caused by a contusion, without fracture, and that thus may be grad- 
ually produced a deformity 
Fig. 201. clinically identical with that 

following fracture. I have 
given elsewhere l reasons for 
deeming this theory incorrect 
and for believing all such al- 
leged cases to be those of un- 
recognized fracture. 

Other specimens, and they 
are numerous, show an abun- 





dant production all about the 
trochanter and upper end of 
the shaft. In part this en- 
largement is due to splitting 
and displacement of the frag- 
ments, but the greater part of 
it is new bone produced sub- 
periosteally, or, more prob- 
ably, by ossification of the 
attached fibrous and tendi- 
nous tissues. This is espe- 
cially common at the back, 
along the intertrochanteric 
line. Sometimes these masses 
so embrace the end of the 

ununited upper fragment (neck) that the patient can walk well without 

the aid of cane or crutch (Fig. 202). 

^Stiuison : " Doubtful Fractures of the Neck of the Femur and their Identity with an 
Alleged Form of Arthritis Deformans,'' New York Medical Journal, April 14, 1838. 



Fracture with absorption of the neck. 



FRACTURES OF THE FEMUR 345 

The cavity of the joint is sometimes diminished by an adhesive syno- 
vitis which, aided by peri-articular thickening and retraction and by the 
above-mentioned osteophyte growths, greatly restricts its mobility. 

Occasionally the limb, after either form of fracture, remains useless, 
and much pain is felt, especially if union has failed ; and there are a 
few recorded cases in which suppuration has occurred within or without 
the joint. 

The degree of probability of bony union after fracture through the 
neck could be determined only by the statistics of a series of continuous 

Fig. 202. 




Fracture of the base of the neck. Exuberant callus and interlocking of the fragments that per- 
mitted fair use of the limb, notwithstanding failure of union. 

cases. The collation of reported cases is not sufficient because it is 
certain that the proportion of failures of union therein would be dis- 
proportionately large ; the examination post mortem of the part is more 
likely to be made if the patient remains disabled until death than if 
he has regained use of the limb. Most of the specimens we possess 
of bony union have been obtained from patients who died from some 
intercurrent cause within a comparatively short time after the accident, 
while its memory was still fresh. 

Clinical statistics are untrustworthy because of uncertainty as to the 
exact situation of the fracture and as to the extent and character of the 
repair. In respect of the latter it is to be borne in mind that some 
patients have been able to make fair use of the limb even when union 
had entirely failed, and that others (after fracture at the base ot^ the 
neck) have been able to make even less use although bony union had 
taken place. Good union in the young seems, on clinical evidence, to 
have been frequent. 

The facts in our possession are : (1) that bony or close fibrous union 
after fracture through the neck is possible ; [-) that the preservation of 



346 FRACTURES. 

enough of the periosteum of the neck to make a vigorous vitality 
of the head probable is probably common; and (3) that the primary 
displacement usually does not separate the fractured surfaces, so that if 
it is not increased by early attempts to use the limb or, more rarely, by 
the action of the muscles in the absence of proper retention, the condi- 
tions for reunion are favorable. We also know that fair usefulness of 
the limb, even after union has failed, is possible ; and it has not been 
proved that this usefulness is greater or more probable if the attempt 
to secure union has not been made. 

Symptoms and Diagnosis. 

The symptoms of the fracture and the signs upon which the diag- 
nosis must be made include not only the usual objective and subjective 
symptoms of fracture but also the history of the case, the nature of 
the violence, and especially its slight degree, which so often char- 
acterizes this injury. 

Interference with Function. As a rule the patient is unable to use the 
limb, and he is not merely unable to bear his weight upon it, but he 
cannot even move it in bed. Exceptions to this have been already 
mentioned, and it is not particularly uncommon to see patients who, 
while lying on the back, can slowly flex the thigh upon the pelvis 
either by its muscles alone or with the aid of the hands, but they can- 
not raise the foot from the bed, the knee bends at the same time and 
the foot is drawn up toward the body. Most authors have mentioned 
cases in which the patients have walked for longer or shorter distances 
immediately after the injury, and in which the existence of a fracture 
has subsequently become very clear. This is very exceptional, and it is 
sufficient to bear the possibility in mind to avoid the error of inferring 
that a fracture cannot be present because the patient is or has been able 
to use the limb. Frangenheim (loc. cit., p. 449) reports one fifty- 
seven years old, who walked to the hospital fourteen days after the acci- 
dent and complained only of slight pain in the hip. At her death, three 
weeks later, the fracture was found to be at the junction of head and 
neck with sharp angular displacement, apex forward. In the slighter 
cases in the young the patients have sometimes walked for several days 
before shortening and disability suddenly appeared. See Blecher 
(Deutsche Zeitschrift fur Chir., vol. 77, p. 302) for four such personal 
cases ; the patients were twenty and twenty-two years old, and the 
fracture at the middle of the neck. 

The opposite error, that of supposing a fracture to exist because the 
limb has been disabled by a fall, can be easily made, because a simple 
contusion may cause eversion of the limb as well as ecchymosis and 
swelling, and in some cases fracture causes no other symptoms than 
these. Observation of the case for a few days will make the diagnosis 
clear. Whitman (loc. cit.) claims that in the young the disability is 
usually much less than in the old, and that in many instances the pa- 
tients are able to walk after a few days. 

Pain is always present. It is usually slight, or even absent, when 
the patient is at rest, but is readily excited by even slight communi- 
cated or voluntary movements. It is referred sometimes to the region 



FRACTURES OF THE FEMUR. 347 

of the trochanter, sometimes to the groin or inner and upper portion 
of the thigh. Sometimes pressure with the end of the finger detects 
a particularly sensitive point in the line of the neck in front just out- 
side the great vessels, or at the corresponding point behind. Forcible 
pressure upward against the foot or inward against the trochanter fre- 
quently fails to cause pain. 

The posture and appearance of the limb are so characteristic that it 
is sometimes almost safe to make the diagnosis by simple inspection. 
As the patient lies upon his back the affected limb appears shorter than 
the other, everted, and slightly flexed and abducted, and conveys an 
impression of helplessness that is often very striking. The upper por- 
tion of the thigh is swollen in front and on the outer side, and ecchy- 
mosis sometimes appears after a day or two. The greater the shortening 
the more marked is this swelling. 

Eversion may be so marked that the foot rests entirely upon its 
outer border as the patient lies upon the back. In other cases it is so 
slight that, as Prof. Bigelow has pointed out, it is best recognized by 
comparing the extent to which the two feet can be inverted. 

In exceptional cases the limb is inverted ; it is either found so on 
the first examination or it becomes so after a day or two. 

The cause of the eversion is probably almost always mechanical ; it 
is largely the effect of gravity acting upon the limb under changed 
conditions of support. It is favored by angular displacement at the 
fracture. On the other hand, eversion has been observed in cases of 
simple contusion, and in others of fracture in which there was no dis- 
placement of the fragments, no rupture of the periosteum even, and 
consequently no loss of support. When one lies upon his back a dis- 
tinct, although slight, effort is required to keep the toes upright ; the 
natural tendency of the limb is toward eversion, particularly if the 
knee is slightly flexed, and this tendency which is increased by any- 
thing that diminishes the activity of the muscles must be taken into 
account in those obscure cases where the diagnosis lies between a con- 
tusion and a fracture. 

The cause of inversion is not so clear. Smith attributes it to the 
position of the fragments relative to each other, and says that in all 
the cases of inversion which he was able to examine post mortem he 
found the lower fragment in front of the upper one. This, however, 
does not always explain the symptom when the fracture is of the nar- 
row part of the neck, intracapsular, although it may do so in some, 
as in the case observed by Goyrand l where the neck had slipped behind 
the head and was fixed between it and the capsule. 

The diagnostic value of the posture of the limb, as regards eversion 
or inversion, is not very great, for inversion is a symptom that needs, 
as it were, to be explained away, and eversion may be due to a simple 
contusion. In order to estimate the degree and persistence of the ever- 
sion the patient should be placed flat upon his back with the thigh and 
leg extended. A comparison with the other foot will then show the 
degree of the eversion, and gentle efforts to rotate the limb will show 
to what extent and in what manner the movements are restricted. 

Shortening of the limb is produced either by alteration ot % the angle 
1 Goyrand : Diet. EncyclopSdique, art. Cuisse, p. 239. 



34* 



FRACTUlim. 



between the shaft and the neck or by overriding, and may vary in 
extent from a small fraction of an inch to two or three inches. It 
may be present at its maximum immediately after the accident, or it 
may be absent at first and appear gradually or suddenly after the lapse 
of a few hours or days, or may increase gradually or suddenly. It is 
usually held that when the fracture is of the narrow part of the neck 
(intracapsular) the shortening is absent or slight at first, increases 
more or less gradually, and never exceeds one and a quarter inches ; 
and gradual increase in the amount of shortening is claimed by some 
to be pathognomonic of this variety of fracture. These statements are 
true only as an expression of the average condition ; m exceptional 
intracapsular cases the shortening may exceed this amount, and in 
fractures at the base of the neck it may increase gradually in the same 
manner. Dietzer (Deutsche Zeitschrift fur Chir., vol. 64, p. 63) reports 
a unique case of lengthening, 2 cms. 

In measuring the limbs care must be taken to have them form the 
same angle with the pelvis, that each is in the same position of exten- 
sion and abduction. If the injured limb cannot be brought parallel 
to the median line of the body the other must be abducted to the same 
degree. To insure this symmetry it is well to stretch a cord downward 
at right angles to and from the centre of another cord stretched between 
the two anterior superior iliac spines, and then to place the ankles at 
equal distances from it and as near to it as is convenient. The meas- 
urements are usually made between the anterior superior spine of the 
ilium and a malleolus. 

Another method of recognizing shortening and of measuring its 
extent is one recommended by Mr. Bryant, measuring to the trans- 
verse vertical plane passing 
Fig. 203. through the anterior superior 

spinous processes. Thus, in 
Fig. 198 a c represents the 
vertical plane passing through 
these processes, and 6 is the 
top of the great trochanter. 
In fracture of the neck with 
shortening b is brought nearer 
to e. The same care must be 
taken to have the limbs in 
symmetrical positions, and I 
have found it convenient to 
mark the vertical plane by placing a small stick or pencil upright beside 
the pelvis and in line with the processes, and then to measure the dis- 
tance between it and the trochanter. The same measurement can be 
made, roughly but usually with sufficient accuracy, by placing the 
thumbs on the superior iliac spinous processes and the tip of a finger 
on each trochanter, and thus estimating the comparative levels. 

Another but less accurate method of recognizing the elevation of 
the trochanter is to find its position with reference to " Nekton's line," 
the line taken by a cord stretched between the tuberosity of the ischium 
and the anterior superior spine of the ilium. Under normal conditions 




Bryant" s iliofemoral triangle, for diagnosis of frac- 
ture of the neck of the femur. 



FRACTURES OF THE FEMUR. 349 

this line crosses the top of the trochanter when the thigh is slightly 
flexed on the pelvis. 

Attention has been called by Dr. Allis to an effect of this shortening 
which can be easily recognized ; the relaxation of the fascia lata between 
the ilium and the trochanter and just above the knee on the outer side. 

Another effect is the broadening and thickening of the upper por- 
tion of the thigh, a change in shape which the eye learns to recognize 
as almost pathognomonic. 

The shortening can sometimes be overcome, entirely or in great part, 
by gentle traction upon the limb combined with enough rotation inward 
to correct such eversion as may exist. I think the dread of separating 
impacted fragments by traction has been exaggerated. The penetra- 
tion is transverse, and longitudinal traction that is not violent enough 
to cause much pain cannot do more than change the angle at the junc- 
tion of the neck and shaft, it does not separate the fragments from each 
other. Rotatory movements communicated to the limb are more likely 
to do harm, as is also such lack of support as will allow the eversion 
and shortening to be increased. 

Crepitus is occasionally perceived during the manipulation of the 
limb while making either traction or rotation, in the latter especially 
if the limb is at the same time flexed ; but it is far from being a con- 
stant sign, either because of impaction or of splintering that leaves the 
pieces too closely connected to produce it. The sign is one that should 
not be repeatedly sought for ; in the cases that are really obscure it is 
highly improbable that it can be obtained, and in the others it is not 
needed. The failure to obtain it on examination has led to many 
costly errors in diagnosis. 

Among other signs which may be present are enlargement of the 
great trochanter when it has been split or comminuted, or the appear- 
ance of its enlargement by the inflammatory thickening of the over- 
lying soft parts, change in its distance from the median line of the 
body, change in the centre of rotation of the limb, and change in the 
depressibility of the outer portion of Scarpa's space. 

The enlargement of the trochanter in consequence of its having been 
split by the outer end of the neck is sometimes very marked and easily 
recognized before the soft parts have become swollen by grasping it 
between the thumb and fingers. The similar enlargement due to 
infiltration of the adjoining soft parts is always present in fracture at 
the base of the neck after a day or two. 

The distance between the outer face of the trochanter and the median 
line of the body may be increased or diminished, but the change is 
seldom very marked and is difficult of accurate determination. It is 
easier to prove that it ought to exist on theoretical grounds than to 
recognize it if actually present. If the neck is driven into the tro- 
chanter the distance of the trochanter from the cotyloid cavity is dimin- 
ished by the amount of the penetration ; if, on the other hand, there is 
no penetration or crushing and the displacement is an angular one in 
the frontal plane, the bone being pushed up until the angle at the 
junction of the neck and shaft becomes a right angle, the distance is 
increased because the neck then stands directly out from the body 
instead of being inclined downward ; and thirdly, in combinations of 



350 FRACTURES. 

penetration and this angular displacement the two changes may neu- 
tralize each other in whole or in part. 

Rotation of the trochanter upon a shorter radius than usual is 
another symptom found in the text-books but not often at the bed- 
side. Theoretically, if the lever upon which rotation is made is broken 
a new centre is formed at the seat of fracture or the radius is shortened 
by impaction. Nothing could be simpler or more accurate in theory, 
but in practice it is beset with difficulties that make it worthless as a sign, 
for it is recognizable only in cases where the diagnosis cannot be in doubt. 

It is practically impossible to tell by pressing the finger against the 
outer face of the trochanter whether it rotates upon a long or a short 
axis, for the range of permissible motion is too limited to make it pos- 
sible to recognize the sharpness of its curve. In cases of fracture with 
crushing of the neck and when the shaft lies unconnected with the 
remainder of the neck and the head, rotation of the limb may take 
place about the longitudinal axis of the femur, and the centre of motion 
lie within the shaft, not outside of it in the cotyloid cavity, and this 
can sometimes be recognized by pressing the finger against the posterior 
face of the trochanter and rotating the limb gently. Instead of rising 
from the finger the bone may be felt to slide over it. Or pressure 
against the back of the trochanter may simply raise it, instead of 
inverting the foot. 

The change in the depressibility of Scarpa's space signalized by 
Hennequin l is a valuable diagnostic symptom. Under normal condi- 
tions the fingers can be pressed deeply into the limb in the outer por- 
tion of Scarpa's space, but when the neck of the femur is broken this 
depressibility is reduced in varying degrees, apparently by the angular 
displacement (with the apex directed forward) which takes place so 
commonly at the junction of the neck and shaft or by infiltration of 
the soft parts. The same condition was described by Laugier 2 as a 
sort of bony tumor to be felt on the outer side of the great vessels an 
inch or two below Poupart's ligament, slight pressure upon which was 
painful. 

Diagnosis. 

In most cases the existence of a fracture of the neck of the femur 
can be readily determined and sometimes its variety can also be easily 
recognized, but in others the main character of the injury is very 
obscure, and, when the presence of fracture is evident, it may easily be 
impossible to distinguish positively between the two forms. The means 
by which they may be distinguished are described below. 

When the symptoms described above are clearly marked, when there 
is the history of a fall followed by complete loss of power in the limb, 
with shortening, eversion, crepitus, pain at the hip, and elevation of 
the trochanter, there can, of course, be no doubt — the neck of the 
femur is broken. But when the limb is not entirely powerless, when 
the shortening and eversion are slight, perhaps even doubtful, when 
crepitus is not felt, when, in short, there is no single positive sign, the 
temptation to conclude that there is no fracture is great, and although 

1 Hennequin : Des Fractures du Femur, p. 700. 

2 Laugier : Diet. Encyclopedique, art. Cuisse, p. 507,: 



FRACTURES OF THE FEMUR. 351 

the warning uttered by Hodgson nearly a century ago, that inability 
in an elderly patient to use the limb after a fall upon the hip should 
be deemed evidence of probable fracture of the neck of the femur, lias 
been repeated many times since, it is still very often disregarded to the 
great damage of the patient and sometimes also of the surgeon. The 
rule should be firmly established in practice that every doubtful case, 
especially in the elderly, should be treated at first as a fracture, and all 
the more so if the violence has been comparatively slight, such as a 
stumble or a fall while walking. It has been said that the pain of a 
contusion or sprain is most marked on moving the limb, that of a frac- 
ture on trying to bear the weight of the body upon it ; but even if the 
statement is accurate, which I doubt, it would be very injudicious to 
make the test, for if fracture is present the effort to bear the weight 
upon the limb would be likely to separate the fractured surfaces and 
increase the displacement and the chances of failure of union. If the 
injury is not a fracture the rest and even the confinement to bed can 
do no harm and are but a small price to pay for the avoidance of the 
grave risks involved in the neglect of the precaution so long as it is 
possible that the injury is a fracture. 

The examination should be directed first to the history of the case, 
then to the functions of the limb and the pain, then to its attitude and 
length, the condition and height of the trochanter, and the depressi- 
bility of Scarpa's space. If any doubt then remains the limb may be 
gently rotated, in order to judge of the degree of eversion and of its 
mobility, and, if desired, to estimate the radius of rotation, and perhaps 
incidentally to elicit crepitus. 

A possible source of error in the existence of a former fracture, or 
of a deforming or dry arthritis, to which a fresh contusion has just 
been superadded, must be borne in mind when the history of the case 
is inquired into. 

Dislocation is eliminated in case of eversion by noting the absence 
of the head of the femur from the pubic region. The exclusion of 
dislocation backward upon the ilium in case of fracture with inversion 
of the limb may be more difficult. In dislocation the limb is more fixed, 
it is adducted and flexed, the trochanter is prominent, the head of the 
femur may perhaps be felt posteriorly, and its absence from the cotyloid 
cavity be recognized by palpation. In fracture the inversion may give 
place to eversion after traction upon the limb. 

Fracture at a lower level is recognized by the seat of pain on direct 
pressure and usually by the failure of the trochanter to share in rota- 
tory movements communicated to the lower portion of the limb. 

Fracture of the acetabulum with penetration of the head of the 
femur into the pelvis has usually been mistaken for fracture of the 
neck of the femur. The means of diagnosis has been mentioned in 
the preceding chapter. 

In regard to the differential diagnosis between fractures through the 
neck (intracapsular) and those at the base (extracapsular) it can only 
be said that most of the latter can be positively recognized by sensitive- 
ness on pressure along the line of fracture and by the thickening recog- 
nized by grasping the great trochanter between the thumb and finger-. 



352 



FRACTURES. 



a thickening due either to splitting of the trochanter or to infiltration 
of the overlying soft parts starting from the fracture ; and some of the 
former almost as positively by exclusion aided by the age of the patient, 
the slight violence, the absence of thickening and sensitiveness to 
pressure about the base of the neck, and the absence or the slight 
amount of the shortening, but in many cases the distinction cannot be 
made. Thickening about the trochanter and base may be a little de- 
layed. Anaesthesia makes the recognition of some of the signs easier, 
but is likely to lead to unnecessary handling and to increase the dis- 
placement. 

In the young, before shortening and disability have occurred, a posi- 
tive diagnosis without the aid of the «r-rays may be impossible. 

Prognosis. 

In this must be considered the immediate danger to the life of the 
patient created by the accident, and the remoter influence upon the 
functions of the limb. In five years during which the published 

records of the New York 
Hospital differentiate be- 
tween fractures of the neck 
and of the shaft thirty-three 
cases of the former were re- 
ceived, with one death; but 
as the average stay was only 
thirty days, it is probable 
that fully half of them were 
transferred to other institu- 
tions within a day or two 
after their receipt, and the 
actual mortality was greater. 
Ashhurstand Xewell, 1 tab- 
ulating the cases received 
during three years at the 
Episcopal Hospital, Phila- 
delphia, found fifty-eight ca- 
ses with sixteen deaths. 

The promptly fatal cases 
present three principal forms: 
in one the primary inflamma- 
tory reaction is sharp, fever 
sets in, the patient becomes 
delirious and dies within a 
few days, or pneumonia is 
developed soon after the ac- 
cident and proves fatal. In another the patient, old and feeble, seems 
overwhelmed by the mental and physical shock and dies within two or 
three days. In the third form the patient's strength fails rapidly with- 
1 Ashhurst and Newell : Annals of Surgery, 1908, vol. 48, p. 748. 




Ununited fracture of the neck of the femur, showing the 
hypertrophied outer fasciculous of the T-ligament support- 
ing the weight of the body in walking. (Bigei.ow.) 



FRACTURES OF THE FEMUR. 



353 



out much inflammatory reaction from the injury, an., he dies asthenic, 
with mild delirium, and usually with some pulmonary consolidation, 
about the third week. It is possible that fat embolism, especially of the 
lungs, may be an important factor in producing this result. The influ- 
ence of age upon the prognosis is very well marked, the older the patient 
the greater the probability of a fatal termination within a few weeks. 

The influence of the seat of the fracture upon the prognosis in respect 
of repair has been discussed above. Speaking generally, union may be 
confidently expected in frac- 
tures at the base of the neck, FlG - 205 - 
and I believe that it is much 
more common after fracture 
through the neck than has 
been supposed, and that this 
frequency can be increased by 
appropriate treatment. But, 
on the other hand, union 
takes place almost inevitably 
with some deformity and with 
some limitation of motion at 
the hip ; the limb is short- 
ened and everted, and abduc- 
tion is diminished by the 
change in the angle of the 
neck with the shaft. This 
shortening may be slight, but 
it causes more of a limp than 
an equal amount in the line 
of the shaft does, because a 
compensatory abduction of 
the limb is not so easily made. 
The limitation of motion is 
seldom enough to cause much 
inconvenience, but the joint 
may be sensitive to fatigue 
and weather and may even be persistently painful. Very satisfactory 
usefulness is possible even in advanced age. 

Failure of union — bony or fibrous — does not necessarily cause com- 
plete disability. There are a number of specimens of complete failure 
of union obtained from patients who have made considerable use of the 
limb for several years after the fracture; they show usually complete 
disappearance of the neck and smooth opposing surfaces on the head 
and side of the shaft, One of Bigelow's specimens shows a similar 
condition with marked displacement upward of the shaft, the weight of 
the body having apparently been borne upon it by suspension through 
the Y-ligament and the obturator and inferior gemellus. A mono- later 




The same, seen from behind, showing the tense obtu- 
rator tendon and the hypertrophied inferior gemellus. 
(Uigelow.) 



specimens reported with interesting details are two by Reboul 1 and 



one 



23 



1 Reboul : Bull, de la Soo. Anat., May 25, 1885, 



354 FRACTURES. 

by Bryce. 1 In such cases that have come under my observation the 
usefulness of the limb has been slight, although there was good motion 
and little or no pain ; the patient walks with a marked limp, only with 
the aid of a cane or crutch, and usually bearing the weight only moment- 
arily upon the limb. In the case represented in Fig. 202 the patient 
walked without a cane. In other cases the pain has been so great 
and constant that excision of the upper fragment has been done for its 
relief. 

Occasionally, especially in the old and rheumatic, the joint remains 
stiff and painful even after union has taken place, and sometimes the 
new formation of bone upon and about the trochanter is so great that 
it notably restricts motion in the joint. 

Ashhurst and Newell (above quoted) traced 21 cases ; of these, 5 had 
a " perfect functional result " (no limp ; 2 apparently were children), 8 
had "no disability but limp," 6 had "marked impairment of function" 
(could walk with aid of cane or crutch), and 2 were " incapacitated." 

Mr. Bryant's 2 statement that all his hospital cases for many years 
(forty-two cases, average age seventy) "went out with good and useful 
limbs " indicates results much better than any others I have knowledge 
of, even if his standard of "good and useful" is only that the patient 
can stand and walk a little with the aid of a cane. 

The coxa vara which is seen after some separations of the epiphysis 
or fractures close to the head in the young is, sometimes at least, due to 
late changes in the shape of the neck (Fig. 182) which are thought to 
be the effect of the changed stresses of pressure^upon the growth of the 
bone. 

Treatment. 

The attainment of the ideal object of treatment — restoration of 
form and function — is rarely to be expected or even sought ; the 
lack of control of the upper fragment and the destruction of tissue 
by crushing prevent the restoration of form, while the proximity or 
involvement of the joint, combined as it usually is with advanced age, 
insures limitation of function. In addition, the danger to life in weak 
and aged patients from measures which cause pain and insure rigid 
confinement is such as to forbid in such cases the use of means by 
which alone the displacements could be corrected and sometimes even 
of those by which union is to be sought. The first indication is to 
save life, the second to get union, the third to correct or diminish dis- 
placements. 

The vital indication often forbids the use of an anaesthetic to complete 
the diagnosis or to correct the displacement, even if either should be 
deemed very desirable, and sometimes, as when pulmonary or heart 
disease is present, even prevents the recumbent position and conse- 
quently the use of means of retention which otherwise would be chosen. 

Reduction of the displacement, which is not only desirable and proper 
but also essential to repair in many fractures of the neck, may be dis- 

1 Bryce : Glasgow Medical Journal, July, 1892. 

2 Bryant : Lancet, 1880, vol. i. p. 160, and British Medical Journal, Oct. 12, 1895, p. 889- 



PLATE XXXV 




Fig. 1.— Fracture of Neek of Femur, in a Boy, aged sixteen. 




Fig. 2.— The same as Fig. 1, after traction. 



FRACTURES OF THE FEMUR. 355 

advantageous in others, and especially in fractures at the base with 
crushing, because it would increase the difficulty of repair by creating 
a gap between the fragments. Thus, if the angle of the neck with the 
shaft has been diminished by crushing at the lower part of the neck 
(Fig. 195), or if the posterior portion has been similarly crushed (Fig. 
183), the correction of the displacement (shortening in the first, eversion 
in the second) would separate the fractured surfaces so far as to endan- 
ger union. And the forcible breaking up of a tight impaction may also 
endanger repair by creating a mobility between the fragments which 
it may be difficult to control by apparatus. As the presence or absence 
of tight impaction or of crushing cannot often be recognized with cer- 
tainty, and as the consequences of an uncorrected displacement are not 
serious, it has long been the rule of practice to make no attempt to 
correct eversion or slight shortening and to seek only to prevent their 
increase. In marked shortening and in most fractures through the 
neck the limb can usually be drawn down easily to or nearly to its full 
length, and this much at least is certainly permissible. Forcible correc- 
tion under ether, recommended by Senn and recently again by Southam 
and Whitman, should be limited, in my opinion, to the relatively young 
and robust patients with fracture at or near the base of the neck, and 
even in them the same result can be obtained by continuous traction. 
The generalization of this hasty forcible correction by wide abduction 
has of late been urged, it seems to me, with more zeal than attention 
to the anatomy of the region and pathology of the injury. No abduc- 
tion which is wider than a normal neck will permit can recreate a nor- 
mal neck. The alleged use of contact between the top of the great 
trochanter and the ilium as a fulcrum for such abduction is fanciful ; 
no dissected hip that I have examined would permit the trochanter to 
be brought within an inch of such contact while the head remained in 
its socket, and even the less extreme manipulations seem to me to be 
dangerous in some, and in others futile, because of the lack of control 
over the position of the proximal fragment. In a fracture at the base 
the position of the proximal fragment may be sufficiently controlled by 
the capsule to permit change in its relations with the shaft to be effected 
by movements of the limb, but in fractures of the narrow part of the 
neck, within the capsule, no intelligent control of the proximal frag- 
ment, no designed change in its relations with the shaft is practicable. 
I am convinced that in the old the practice would be deplorable and in 
the young no more effective than continuous traction. Plate XXXY. 
shows the change in the angle of the neck thus effected. The main- 
tenance of abduction which forms part of the same proposed practice is 
also an imaginary difference, for continuous traction assures, and always 
has assured, abduction of the joint by tilting of the pelvis even when 
the limb is in line with the body. Except when the fragments are 
completely separated from or loose upon each other, as after crushing or 
absorption of the neck, abduction (within a moderate range) takes place 
in the joint more easily than at the fracture and cannot greatly affect 
the relations of the fragments. 



356 



FRACTURES. 



Retention has for its object to maintain the position of the limb 
against the displacing action of the muscles and gravity, to keep the 
fractured surfaces in contact, and at the same time to permit a certain 
general freedom of motion to the patient which will facilitate the atten- 
tions necessary to meet his wants, preserve cleanliness, avoid bed-sores, 



Fig. 208, 




Combined suspension and traction. 

and diminish the general ill effects of restraint. The means employed, 
in their order of frequency, are continuous traction, immobolization by 
splints with or without direct pressure upon the trochanter, and fixation 
of the fragments by nails or sutures. 

It has long been noted that satisfactory functional results can some- 
times be obtained by simple rest in bed for a few weeks with only such 
support for the limb as can be given by cushions or a long side-splint 
without traction or a double inclined plane, but it is always advisable 
and sometimes absolutely necessary to use means which will more surely 
give the necessary immobilization in the proper position. 

Continuous traction can be made by weight and pulley (Buck's 
extension), or by Hodgen's suspended splint, or by a combination of the 
two, or in combination with a long side-splint or hip-splint. The 



FJRACTUBES OF THE FEMUR. 357 

details of their application are given in Chapter \l\. If Buck's ex- 
tension is used the foot and leg should lie upon a Yolkmann's sliding- 
rest (Fig. 43) to promote comfort and oppose eversion of the limb, 
and a small firm cushion should be placed behind the trochanter. 
Direct pressure upon the outer aspect of the trochanter to press the 
fragments together can be made by a padded band about the pelvis. 
The weight varies from five or ten pounds in the old to fifteen or 
twenty in the young adult. If Hodgen's splint (Fig. 44) is used, the 
traction can be made greater or less by changing the angle of the 
supporting cord ; thus, in the old its upper attachment should usually 
be about a foot beyond the vertical (at a height of about five feet), and 
more if more traction is desired. The limb should swing just free of 
the bed, somewhat abducted. The Hodgen splint greatly promotes 
the patient's comfort and is generally to be preferred, I think, to the 
other methods of traction. In this statement I include its use for 
simple vertical suspension while traction is made by Buck's extension 
(combined suspension and traction, Fig. 206). 

Hennequin 1 makes traction by a band crossing the front of the thigh 
close above the knee and passing across and behind the upper part of 
the partly flexed leg, the thigh being supported in a wire gutter. The 
leg and foot, thickly wrapped in cotton, rest on a chair beside the bed, 
or in a gap made by cutting out the lower part of the mattress on that 
side. 

Outward traction upon the upper part of the thigh, by weight and 
pulley and a band passing about the inner side of the thigh, has been 
occasionally employed. I doubt both its efficiency and its advisability 
if efficient ; the former because of the opposition of the abductors 
which should be made relatively tense by the longitudinal traction, and 
the latter because if there is any crushing a gap might be created 
between the fragments which would endanger union. Ruth, 2 who 
strongly recommends it and reports many excellent results, precedes it 
with forcible correction of the displacement while the hip is flexed at a 
right angle, to which, perhaps, any superiority in result which may 
exist should be attributed. 

The combination of continuous traction and immobilization by a 
splint is effected in various ways. The older method was the long 
single or double side-splint with elastic traction, as shown in Fig. 4(). 
Its objectionable feature is the general restraint and immobility which 
it imposes and which the aged do not bear well. Lighter and shorter 
splints with a perineal band for counter-extension, and with traction 
by screws and springs, such as that shown in Fig. 47, are freer from 
this objection. 

The various metal splints designed for use in hip-joint disease have 
of late come into some use in the treatment of these fractures, and this 
use might, I think, be advantageously extended, certainly in the 
younger cases. Such an apparatus can be used simply for immobili- 
zation, as in the Thomas splint, or combined with traction in the usual 

1 Hennequin : Fractures des os Ionics, 1904. 
Ruth : Therapeutic Gazette, March 15, 1907. 



358 



FRACTURES 



manner. With its aid, especially if supplemented by a pelvic band 
or a pad to press upon the trochanter, the patient, if not too old and 
feeble, can leave the bed by the fourth or fifth week, sometimes even 
earlier, and go about on crutches. Shaifer 1 has reported two very inter- 
esting and suggestive cases in which by the aid of such a splint with 
traction and trochanteric pressure he obtained good union, although 
treatment was begun in one three months, in the other nine months, 
after the receipt of the injury. In his first case the trochanteric press- 
ure was made by a pelvic band, in the second by a tourniquet ; it could 
be increased and diminished at will and was borne without discomfort. 
In both cases the fracture was thought to be through the neck (intra- 
capsular), and the patients were young men. They mark an important 
advance in the treatment of failure of union and suggest the more gen- 
eral use of trochanteric pressure, especially in fractures through the neck. 
Encasement of the limb and pelvis in plaster of Paris is occasionally 
used, but the discomfort and inconvenience of the method are great and 
add to the danger to life in the aged. Senn applied the plaster to both 
limbs and the pelvis and made pressure by a steel pin passed through 
the soft parts to the outer aspect of the trochanter, but the plan has not 
met with favor and appears to be distinctly inferior to the long traction- 
splint and pressure by a girdle. 



Fig. 207. 



Fig. 208. 





Pertrochanteric fracture. (Kocher.) 



Pertrochanteric fracture. (Kocher.) 



The apparent advantage of a dressing that permits the patient 
promptly to leave the bed is illusory in most cases, for the patients are 
too old and feeble to profit by it ; those that may seem to need the 
change most are the least able to make it, in the others the gain does 
not seem to me to compensate for the risk. In fractures through the 
1 Shaffer : New York Medical Journal, October 23, 1897, p. 557. 



FRACTURES OF THE FEMUR. .359 

neck, and in others in which the transformation of the bond of union 
into bone is delayed such a dressing has great advantages, for it per- 
mits the patient to leave the bed, say in the second or third month, 
without interruption of the immobilization. 

The attempt to secure union by operation, 1 in fresh as well as in 
old cases, has been made many times since Langenbeck's first and unsuc- 
cessful one. The first success was got by Franz Konig in 1875 by 
passing a metal pin through the trochanter, neck, and head, and most 
subsequent ones have been got in the same way. 

The weight of opinion, to judge from the published papers and 
reports of discussions in various surgical societies, is strongly in favor 
of abstention in fractures at the base of the neck. The occasional suc- 
cesses obtained in old cases are matched by those obtained by splints. 

In fracture through the narrow part of the neck the question is still 
an open one and presents itself in two forms : Shall the attempt be 
made in a fresh fracture? Shall it be made in an old fracture or shall 
excision of the head be preferred ? Here, too, the weight of opinion 
has been decidedly against operation in fresh cases, and seems to be 
fully justified by the known pathology of the injury and the belief 
that the preservation of the blood supply of the head is essential to 
repair. Suturing the periosteum, if it has been torn, cannot be ex- 
pected to restore this blood supply sufficiently soon and abundantly to 
do any good ; and if the periosteum has not been torn, suturing of the 
bone is superfluous and correction of the angular displacement will 
only open a gap on the concave side which will diminish the breadth 
and consequently the strength of such union as may be obtained. 
Fritz Konig, after four attempts at late suture, got a good result in an 
early one and obtained the specimen a few months later. He found 
firm union (bony ?) in front where he had sutured bone and periosteum, 
and a gap behind where he had placed no sutures, and on the strength 
of this he argues for operation at the end of the first week and for 
suturing all around, attributing the gap to the absence of sutures. It 
can, with greater plausibility, I think, be charged to correction of the 
displacement. Late attempts to get union have given few results that 
can be called even moderate successes, and Konig' s opinion that if it 
is to be done at all it should be clone early is doubtless correct. 

Excision of the head 2 in old cases for the relief of pain and improve- 
ment of function has given a number of good results. For the at- 
tempt to get union and also for excision Fritz Konig recommends the 
anterior approach by an incision between the tensor vaginae femoris on 
one side and the rectus and sartorius on the other. Ito and Asahara, for 
excision, used the posterior route, the Langenbeek or Kocher incision. 

i Konig, Chirurgie, 5th Ed. /vol. 3, p. 282; Loretta Brit, Med. Journ,. Aug. 25, 1SSS; 
Cheyne, Ibid., March 7,' 1892; Dollinger, Centralblatt fur Chir., June 6, 1S92; Meyer, 
Annals of Surg., July, 1893; Kocher, Wiehtiger Frakturformen, p. 303; Freeman. 
Annals of Surg., Oct. 1904, p. 561; Fritz Konig, Arch, fur klin. Chir., vol. 76, p. 725: 
Schlange, Ibid., vol. 81, part 2, p. 26; Vaughan, Am. Journ. Med. Sci., March. 1907. 
p. 385; Herz, Ztlblatt Mr Chir., 1906, p. 705; Flint, Annals of Surg. 190S, vol. 48, p. 
729. 

2 Howe, Med. Record, vol. 14, p. 394 ; Fritz Koniz, Chirurgie, vol. 3. p. 252: Lejars, 
Semaine med., Oct. 17, 1894; Bolton ? Annals of Surg., Feb., 1900, p. 149, Ito and 
Asahara, Deutsche Zeitschrift fiir klin. Chir., vol.78, p. 121, 7 cases; Fritz Koni... 
loc. cit. 



360 FRACTURES. 

C. Fractures Through the Great Trochanter and Neck. 
(Fractura Pertrochanterica, Kocher.) 

This class may be defined as composed of those cases in which the 
line of fracture begins at or near the lower part of the junction of the 
neck and shaft and passes through or close below the great trochanter, 
dividing the bone into two parts, of which the upper is formed by the 
head, neck, and upper part of the trochanter. The line of fracture 
may be oblique from within outward and upward, or from behind 
upward and forward. The line of division between these and the 
subtrochanteric fractures, the highest of the fractures of the shaft, is 
marked by the trochanter minor, which also establishes an important 
clinical difference depending upon the action of the psoas-iliacus which 
is attached thereto. Its action in fractures below that point is to flex 
the upper fragment. 

The injury is not a common one, and the recorded specimens are 
few. To those described in the first edition may be added three from 
the museum of Trinity College, Dublin, shown by Bennett 1 to the 
British Medical Association, and five described and figured by Kocher. 
The illustrations of Bennett's are so indistinctly printed that the details 
are not recognizable ; in two of them the fracture appears to have ex- 
tended down the outer part of the shaft. Kocher's 2 specimens show 
marked angular deformity, apex forward, and some diminution of the 
angle of the neck, adduction of the shaft (Figs. 207 and 208). 

The only one I have seen differed notably from the type-form in 
that the line of fracture was very long and oblique; extending from the 
top of the trochanter downward and inward to a point which I thought 
was well below the lesser trochanter. Because of persistent displace- 
ment and some uncertainty of diagnosis I exposed the fracture by an 
anterior incision, but did not uncover its lower end. The patient was 
fifty years old, and recovered with little, if any, shortening. 

The mechanism appears to be forcible extension (possibly abduction) 
of the limb, in which movement the neck and trochanter are arrested 
by the Y-ligament and the fracture takes place below or through its 
lower attachment. 

The characteristic symptom appears to be the prominence of the 
angle in front, with pain on pressure at this point and possibly with 
immobility of the trochanter and crepitus when the limb is gently 
rotated. Shortening and eversion are present, the latter due to mus- 
cular relaxation and loss of control of the lower fragment. In my case 
the trochanter was prominent and eversion marked. 

Treatment. The treatment is immobilization with traction, but pref- 
erably with more flexion of the hip than is usual in fracture of the 
neck. 

1 Bennett: British Medical Journal, October 12, 1895, p. 893. 

2 Kocher : Loc. cit., Figs. 140 and 151-157. 



FRACTURES OF THE FEMUR. 361 

D. Fracture of the Great Trochanter. Separation of the 

Apophysis. 

Only a few specimens, not more than a dozen, of this injury, inde- 
pendent of associated fracture of the neck, have been reported. The 
cause appears commonly to be a blow upon the outer posterior nortion 
of the trochanter ; occasionally muscular action. 

The fragment usually remains attached to the femur by tendinous 
and periosteal fibres, and is sometimes broken into two or more pieces ; 
it is freely movable upon the shaft, but rarely is completely separated 
from it and displaced upward or backward by the attached muscles. 
Potherat 1 reported a specimen, found in the dissecting-room, with dis- 
placement upward of four centimetres. Neck 2 demonstrated by in- 
cision a flat fragment on the outer aspect. 

The specimens of the separation of the apophysis are one in Guy's 
Hospital museum, Key's case (Fig. 209), one in Steevens's Hospital, 3 
Dublin, Hilton's, 4 Ashton's, 5 Adami's 6 and Daniel's. 7 The last four 
are quoted from "Poland. Two of these (Adami's and Steevens Hosp.) 
were obtained in the dissecting-room without history. In the others 
death followed within a few weeks after the violence that was thought 
to have caused the separation, and was preceded by fever and suppura- 
tion about the upper part of the bone. In 
all but one (Daniels) the separation was Fig. 209. 

exactly along the epiphyseal line, and the 
fragment was not displaced ; it seems to me 
highly probable that they were cases of 
osteomyelitis, possibly originating in the 
trauma. 

McCarthy's case seems to me clearly to 
be osteomyelitis rather than fracture. 

Symptoms. The symptoms are local pain 
on pressure, and mobility of the fragment „ 

A • 1 i •/» .1 it • Fracture or diastasis ot the great 

recognizable if the swelling is not too great. trochanter. (Bryant.) 

Most of the patients have been able to walk, 

though with pain ; and rotation of the hip was painful. 

Treatment. The treatment is immobilization, preferably with the 
limb abducted and rotated outward to diminish the displacing action of 
the attached muscles. Local pressure by a bandage about the hips has 
been used, but is probably unimportant. 

E. Fracture of the Trochanter Minor. 

Bennett 8 reports a specimen of this fracture in the museum of Trinity 
College, Dublin, associated with a united intracapsular fracture oi' the 
neck. The accompanying illustration shows the trochanter detached 

Potherat: Bull, de la Soc. Anat., February, 1S88. 

2 Neck: Centralblatt fur Chirurgie, 1903, p/l447. 

3 Transactions Pathological Society of Dublin, vol. vii. n. s., quoted bv Bennett. 

4 Hilton: Guy's Hospital Reports, 1865, p. 342. •> Ashton: Lancet, Feb.', 1876, p. 231, 

8 Poland : Traumatic Separation of Epiphyses, p. 666. 

6 Transactions London Pathological SocietV, vol. xlvii. p. 174. 

7 Bennett : British Medical Journal, October 12, 1S95, p. 893. 




362 FRACTURES. 

with a small portion of the shaft. He adds that he has recognized the 
fracture in the living, but gives no details. 

The only other specimens or cases that I know of are Fen wick's and 
Julliard's. Fenwick's is reported by J. Hutchinson, Jr., 1 : a boy, 
seventeen years old, leaped upon a fence and fell backward, breaking 
off the lesser trochanter, apparently by the pull of the psoas-iliacus. 
This was verified by incision. He died of septicaemia on the seventeenth 
day. The specimen is in the museum of McGill College, Montreal. 

Julliard's 2 patient was a man eighty-two years old and was injured 
by falling as he rose from bed. Severe pain in the hip and marked 
eversion and disability which persisted until his death, a fortnight 
later. Diagnosis, fracture of the neck of the femur. The autopsy showed 
a large extravasation of blood in the muscles, the joint and neck of the 
femur intact, the lesser trochanter broken oif and adherent only by a 
strip of periosteum. " The upper extremity of the femur shows a cavity 
as large as a small nut and presents a sarcomatous degeneration." 

2. FRACTURES OF THE SHAFT OF THE FEMUR. 

The highest of the fractures considered in this section are the sub- 
trochanteric, the lowest the supracondyloid ; intercondyloid or T-frac- 
tures will be described in the following section. Exceptional and 
irregular forms are occasionally seen, spiral and oblique fractures in 
which the main line or a fissure passes from the upper part of the shaft 
to the neck and the trochanter, and even in which the upper fragment 
has been split longitudinally through the trochanter. 

Causes. The causes of fracture are direct and indirect violence and 
muscular action ; see Chapter III. 

Pathology. All the varieties of fracture that may occur in long bones 
are met with in the femur, but in the great majority of cases the frac- 
ture is oblique and often extremely so, the obliquity usually correspond- 
ing to the normal curves of the bone ; that is, in the middle part of the 
bone it runs from behind forward and downward, and in the upper 
third forward and outward. Transverse fracture is rare in adults, but 
more common in children. 

The displacement is marked, and is the effect of the fracturing cause, 
of the contraction of the powerful muscles of the thigh, and of the 
swelling of the limb beneath the fascia by which it is broadened and 
shortened. The lower fragment usually passes behind and to the inner 
side of the upper one and is sometimes rotated outwardly ; in addition 
there is angular displacement, the angle usually being directed forward 
or forward and outward, but sometimes backward or inward. 

Inclination forward and outward of the lower end of the upper frag- 
ment after fracture in the upper third is the rule and is mainly due 
to muscular action, the contraction of the gluteal muscles and the 
psoas upon the upper fragment and of the adductors and the flexors of 
the leg upon the lower one. The tendency of the former is to tilt the 
upper fragment forward, outward, or in both directions ; that of the 

1 Hutchinson: British Medical Journal, December 30, 1893, p. 671. 

2 Julliard: Progres Med., 1879, vii. p. 825. 



FRACTURES OF THE FEMUR. 



363 



latter is to draw the lower fragment up against the upper one, and this 
will produce an angular displacement in any direction that is favored 
by the line of fracture. The fact that the displacement is sometimes 
backward or inward does not disprove the influence of the muscles 
attached to the upper fragment, as has been argued; the principal 
agency is the drawing upward of the lower fragment, and if the frag- 
ments are so related at the seat of fracture that the upper one is pushed 
in a different direction from that in which its muscles would draw it the 
latter must yield. In the extreme case shown in Fig. 210 it can be 



Fig. 210. 



Fig. 211. 




Fracture of the upper third of the femur ; union 

with great displacement. (A. Cooper. ) Transverse fracture of the femur. (Gurlt. ) 

seen how great the angular displacement and at the same time the over- 
riding can be under these circumstances. The angular displacement 
necessarily produces shortening, and this shortening varies according 
to the angle and, the angle being the same, according to the distance 
of the fracture below the neck of the bone. In the same specimen 
outer rotation of the lower fragment is also very marked. In trans- 
verse and toothed fractures the displacement may be lateral or angular 
or both, and if the lateral displacement is sufficient to free the frag- 
ments they may override. 

Extreme obliquity of the fracture, which is not uncommon, leads 
occasionally to a complication which may be very troublesome and mav 
transform a simple fracture into a compound one, the penetration of 
the muscle and sometimes of the skin by the sharp end of the upper 
fragment. This is specially likely to occur in fractures of the lower 
third, the sharp lower end of the upper fragment perforating the quad- 



364 



FRACTURES. 



rieeps or even the skin. The perforation of the muscle is directed 
downward as well as forward, probably because the knee is flexed at 
the moment when it occurs, and then when the joint is straightened 
the muscle retracts upward along the spike of bone ; this makes it neces- 
sary to flex the knee again in order to free the bone, thus drawing the 
muscle down past its end. In these fractures of the lower third the 
lower fragment is sometimes tilted (presumably by the action of the 



Fig. 212. 




Fracture of left femur close below the trochanters. 

gastrocnemius) so that is upper end is directed obliquely backward, 
and it is sometimes split by a line of fracture running between the 
condyles. See Intercondyloid Fractures. 

Other complications are rare, the vessels and nerves not only in 
sufficiently close relations with the bone to be often injured. Midler 1 
reported a case of rupture of the inner and middle coats of the femoral 
artery in a fracture at the junction of the middle and lower thirds ; 
gangrene threatening, amputation was done; death. And Selenkow 2 
reported one of laceration of the femoral vein ; death followed, appar- 

1 Miiller : Deutsche med. Wochenschrift, October 11, 1888. 
2 Selenkow: St. Petersburg med. Woch., October 8, 1888. 



FRACTURES OF THE FEMUR. 



305 



Fig. 213. 



entlv the result of officious treatment. The danger is greater in the 
lower third than elsewhere, and pressure upon the vessels when they 
are not torn may cause gangrene of the leg 
either by its continuance or by the formation 
of a thrombus in consequence of the bruising. 

Fissures extending upward and downward 
from the seat of fracture are probably not in- 
frequent, especially in gunshot fractures. 

Double fractures have been observed, and, 
according to Malgaigne, there is a specimen of 
triple fracture in the Musee Dupuytren. Double 
fracture should always be looked for when the 
causative violence has been great. Commin- 
uted or splintered fractures are not uncommon, 
especially among fractures by direct violence, 
and the splinters may be large. 

The effusion into the knee-joint which is 
observed to frequently in the course of fractures 
of the thigh has received particular attention 
since 1870, when Rouge, of Lausanne, first 
wrote concerning it. Among those who have 
studied it most carefully are Gosselin, 1 Berger, 2 
Marjolin, Alison, 3 and Hennequin, 4 the two 
former attributing it to the passage of extra- 
vasated blood into the joint, the third and 
fourth to interference with the return venous cir- 
culation, and the last, in common with Verneuil 
and others, to an associated sprain. Others 
again have sought the cause of the effusions 
noted in the later periods of the case in the 
prolonged immobility and the extended posi- 
tion. An appreciable effusion makes its ap- 
pearance in a majority of the cases within the 
first three days following the injury ; it is most 
prompt in children and when the fracture is in 
the lower third, and is more common after 
fracture by indirect than after fracture by direct 
violence. It disappears promptly in children, more 
and may persist for years. 

Symptoms. The symptoms are pain, loss of function, abnormal 
mobility, deformity, and crepitus. As the bone is deeply placed under 
thick muscles, irregularity in its outline cannot be recognized by the 
touch ; angular displacement can often be readily recognized in thin 
patients by the eye, but the method of examination which renders the 
best service in this respect is the comparative measurement oi \\w two 

'Gosselin: Clinique de l'Hopital de la Charite. - Berger : Those do Paris. 1873. 
15 Alison : These de Paris. 

'Hennequin: Loc. cit., p. 78. (See also the discussions in the Bulletins de la 
Societe de Chirurgie, 1878, pp. (> and 330). 




Fracture of the neck of the 
femur and of the shaft. A 
splinter, 5 inches long and 
nearly 1 inch wide, composed 
of the cortical layer, has been 
turned completely about its 
long axis and become united. 
With its original periosteal 
surface in contact with the 
other fragments. (Figured by 
GritLT from the Museum oi 
the Royal College of Surgeons. 
England, No. 454.) 



slowly in adults, 



SCy(] FRACTURES. 

limbs. The fixed points commonly used for this purpose are the an- 
terior superior spinous process of the ilium and the tip of the external 
malleolus ; the rules for making these measurements and the precau- 
tions to be taken to guard against error have been given in Chapter 
IV. and in the preceding section of this chapter, page 348 ; the capi- 
tal point is to make sure that the two limbs form the same angle with 
the pelvis, and the best method of doing this is to stretch a tape across 
the abdomen from one anterior superior iliac spine to the other, and 
a second one at right angles to the first from its centre downward, 
and then to place the ankles at equal distances from the second line. 
The shortening may vary from a small fraction of an inch to 
several inches. 

Abnormal mobility may be recognized by placing the hand under 
the thigh at the suspected seat of fracture and gently lifting it, or 
by holding the upper portion of the thigh down with one hand and 
gently lifting the leg or moving it from side to side with the other, or 
by observing whether the great trochanter moves with the leg when 
the latter is gently rotated. The examination for abnormal mobility 
and crepitus should be made very gently, and should not be prolonged 
if the latter is not promptly obtained. 

Prognosis. Any fracture of the femur is a serious injury to this 
extent, that its proper treatment makes confinement to the bed for 
several weeks desirable, that it will make it difficult for a long time 
for the patient to get about even with crutches, and that it may lead 
to shortening of the limb, even if not to a persistent limp. It also 

Fig. 214. 




Fracture of the shaft of the femur. 

exposes to the possibility of a fatal result, especially in the aged and 
alcoholic, and to that of gangrene of the limb by rupture or bruising 
of the main vessels or by pressure upon them. 

A simple fracture without displacement, or suitably reduced, will 
usually consolidate in six or seven weeks sufficiently to allow the 
patient to get about on crutches, and he will be able to bear his weight 
safely upon the limb, and to discard the crutches in three or four weeks 
more. In exceptional cases the consolidation may be delayed, and it 
happens occasionally that a secondary fracture occurs soon after the 
partient first leaves his bed, usually in consequence of a fall. 



FRACTURES OF THE FEMUR. 367 

Most authorities assert that an oblique fracture of the shaft of the 
femur cannot be cured without some permanent shortening. Since the 
time of Desault the possibility of a better result has been claimed by 
different surgeons, and for different dressings, but no method has yet 
won a general acceptance of its claim. While there is no reason to 
doubt the possibility of a union without shortening, and while I believe 
such union has been obtained in many cases, I do not believe there is 
any method of treatment which can be depended upon to secure it in 
any given case, for it can never be known in advance whether or not 
the patient will be able or tractable enough to support the traction and 
pressure necessary to success. Some surgeons have claimed an actual 
elongation of the limb by the use of continuous traction. Although a 
certain doubt is thrown over such assertions by the acknowledged diffi- 
culty of making accurate measurements, and by the possibility of a 
previously existing inequality in the length of the limbs, the occur- 
rence is not impossible, however improbable it may be. 

The best series of results of which I have knowledge are those of 
Bardenhauer published by Luxembourg. 1 Of 179 successive cases 
treated in hospital, 1902-06, 157 recovered without shortening, in 15 
the shortening was less than 1 inch, and in 7 between 1 and 1 J inches. 
Ashhurstand Newell 2 found in 17 of the shaft (excluding subtrochan- 
teric and supra-condylar) 5 without shortening, and shortening of one 
centimeter in 8 and two in 4. 

The persistence of some shortening, even an inch, does not necessarily 
cause the patient to limp, since it may be compensated for by an inclina- 
tion of the pelvis. The rigidity in the knee is likely to persist for a length 
of time that is greater if the patient is older and of rheumatic habit. 

The prognosis in compound fractures is particularly grave when the 
injury has been produced by direct violence ; and in a fracture of both 
thighs, particularly if either is compound, the shock is usually so great 
as to put the patient's life in serious danger. 

Treatment. The dressings now in use for the treatment of fracture 
of the shaft of the femur are Buck's extension, Hodgen's suspended 
splint, combined suspension and traction, the long side-splint or the 
hip-splint, usually with traction, encasement in plaster of Paris, and 
the double inclined plane. All have been described in detail in Chap- 
ter VII. It remains only to note their special advantages and indi- 
cations. 

The long side-splint without traction should be used only as 
a temporary dressing during transport or for a few days at first when 
the condition of the patient — delirium, shock, associated injuries — con- 
traindicates one which would not be sufficiently restraining, or the 
application of which would be too exhausting. 

The long side-splint with traction may be used temporarily 
later in the case if the patient is to be transported to a distance ; it is 
cheaper than a hip-splint, can- be readily improvised, and as it extends 
almost to the axilla it nurses greater immobilization. Indeed, the 

• Luxembourg: Deutsche Zeitsehrift fur Chir., 1908, vol. 94, p. 387, 
'-' Ashhurst and Newell : Annals of Surg., 1908, vol. 48, p. 754, 



368 FRACTURES. 

immobilization of the trunk, and the consequent restraint, is the objec- 
tion to its general use. In a somewhat shorter form (Fig. 46), extend- 
ing only to the waist, it is widely used in England throughout the 
course of the case. Weed's splint (Fig. 47) represents a highly 
developed form, adjustable to limbs of different lengths and making 
traction by a spring. 

" Buck's extension " (Fig. 43) is the method in general use in 
the United States and very largely in Europe. It is suitable for the 
great majority of cases, except the subtrochanteric, is easily borne, and, 
as it permits a certain freedom of motion, promotes the comfort and 
well-being of the patient. It also permits constant supervision of the 
fracture and easy recognition of shortening or angular displacement. 
An objection to it is that the patient tends to turn on the injured side 
and thus rotate the upper fragment outward while the lower one and 
the foot are kept upright. This can be measurably met by a small 
firm cushion behind the trochanter, as can also the occasional outward 
rotation of the upper fragment by gravity. In the higher fractures, 
too, it is not always easy to maintain as much abduction of the limb 
as may be desirable. Sagging of the fragments, with production of a 
backward or outward angular displacement, can be prevented by cush- 
ions or a long posterior plaster gutter. 

Hodgen's suspended splint (Fig. 44) gives even greater comfort 
and freedom, permits greater variety in the attitude given to the limb 
— abduction and flexion for the higher fractures — and allows the knee 
to be kept partly flexed, an easier position. It is specially advan- 
tageous in the older and feebler patients. I do not think it immobilizes 
the fractures quite so well as Buck's extension does, but I have found 
no serious inconvenience from this and I use the splint more and 
more in preference even to Buck's, and always in high fractures and 
in those of the lower third ; in the latter because of the flexion of 
the knee. 

Combined Suspension and Traction, (Fig. 206), I can recom- 
mend after two years use as preferable to Buck's or Hodgen's. The 
traction can be more exactly determined and maintained than by the 
Hodgen's, and the patient's comfort is much greater than with the 
Buck's. In addition, lateral pressure to oppose angular or lateral dis- 
placement can be readily made by the upper supporting bands. I 
think it is a real improvement worthy of use. 

The method of making traction by a weight attached to nails driven 
into the condyles has been described in Chapter VII. 

Encasement in plaster of Paris, including the pelvis, after 
having been widely used as the preferred treatment for some years 
after 1870, has now largely given place to continuous traction during 
the first month or six weeks, but is still much used in the later stages 
when displacements are no longer to be much feared and the patient 
needs only to be protected against accident while he goes about on 
crutches and awaits complete consolidation. In case of delayed union 
it may even permit the patient to bear part of his weight upon the 
limb and thus hasten ossification of the bond. It is still sometimes 



FRACTURES OF THE FEMUR. 



369 



used from the beginning, and the patient allowed to go about on 
crutches, but marked displacement can occur under such circumstances 
and the chance, in my opinion, should not be taken. The absence of 
a fixed upper point of support makes it easy for overriding and angular 
displacement to occur. 

The hip-splint, in any of its various forms, meets the same indica- 
tions more conveniently, though more expensively, and as it can be 



Fig. 215. 




Anterior suspended splint, without traction, in compound fracture. 

combined with traction (as in hip-joint disease) it can be safely used at 
an earlier period in the case. It is especially convenient in cases of 
delayed union, for it relieves the patient from confinement to bed. 

The double inclined plane (Fig. 48) is occasionally useful as a 
temporary dressing in very severe injuries when the swelling is great 
or the circulation embarrassed ; also in compound fractures with so 
much loss of bone that traction is not required to prevent overriding. 

The same indications can be met by a long anterior splint flexed at 
the knee and suspended from a horizontal bar placed a short distance 
above it (Fig. 215). Such a splint can be conveniently made of a 
stout iron rod, like Smith's splint (Fig. 37), but it is better to have 
the leg horizontal ; it permits an easy change of the dressings of the 
wound without disturbing the fragments, but, like the inclined plane, 
it needs constant watchfulness to maintain the traction needed to 
keep the fragments in position. 

In fractures of the upper third the thigh should be flexed and 
abducted in order that the lower fragment shall be in line with the 
upper one which usually assumes this attitude, and for this the Hodgen 
splint is the most convenient. 

After five or six weeks, in most cases, abnormal mobility will have 
disappeared or so far diminished that traction is no longer needed ; 
angular displacement is then the only one that is likely to take place, 
and this can be prevented by plaster-of-Paris encasement. It' the 
abnormal mobility has wholly disappeared I usually remove the appa- 
ratus and keep the patient in bed for a few days without any dressing; 
24 



370 



FRACTURES. 



then I apply a plaster dressing, including the pelvis if the fracture is 
above the lower third, and allow him to go about on crutches. After 
another fortnight the plaster is removed. 

In young children vertical suspension is by far the most convenient 
and satisfactory method of treatment. Strips of adhesive plaster are 
applied, as in Buck's extension, to both legs and attached by cords to 
a support immediately above the child so that the pelvis rests lightly 
upon the bed (Fig. 216). I have sometimes made this attachment 
elastic by introducing a rubber cord or by using a support with a flex- 
ible arm, but have found no great advantage in it and some disadvan- 
tage because of the gradual yielding. The fixed support is also better 

Fig. 216. 



1 


■/ 

- \ 

.V. - ' "' 

- 


1 ^^^^ 




\ 



Fracture of the thigh ; vertical suspension. The fracture is compound in the patient on the 

right. 

than the weight and pulley which are sometimes used. The position is 
well borne and makes it easy to keep the child dry and clean. The 
contact with the bed should be so light that the hand can be passed 
easily under the pelvis. In very young children it is sometimes suffi- 
cient to bind the flexed thigh to the abdomen. 

Dr. A. "W. Mitchell devised a splint which permits the child to be 
carried about. It consists of three wooden splints — body, leg, and 
thigh pieces — fastened together by thumb-screws for angular adjust- 
ment. Traction is made by having the thigh piece project beyond the 
flexed knee, so that the bandage about the upper part of the leg will 
draw it downward. 

In older children — over ten years — I have found Buck's extension 
the best, and decidedly preferable to the double side-splint, with which 
it is difficult to prevent shortening and angular displacement. Fairly 
firm union may usually be expected in three weeks. 

In fractures of the lower third the engagement of the lower end of 



FRACTURES OF THE FEMUR. 371 

the upper fragment in the quadriceps, or even in the overlying skin, 
adds greatly to the difficulty of reduction. This can sometimes be 
made by flexing the hip and the knee to a right angle, thus drawing 
the muscles downward along the penetrating fragment, and then com- 
pleting the disengagement by strong traction in the axis of the shaft, 
the flexion being maintained. If this fails the skin and fascia must 
be freely incised over the end of the fragment and the bone disengaged 
by direct manipulation. If the point of the bone has perforated the 
skin the opening should be enlarged, both to facilitate the disengage- 
ment and to evacuate the extravasated blood. The Hodgen splint 
should be preferred in the treatment of these fractures, for it permits 
moderate flexion of the knee and thus tends to avoid the tilting of the 
lower fragment which may happen when the knee is kept extended. 

If the artery is torn it may be tied in the wound ; if the vein alone 
is torn it may be tied, or, if not torn entirely across, the deep soft parts 
may be sutured over it so as to oppose escape of the blood, and the 
attempt made to save the limb, but if gangrene appears amputation 
must be done at once. Division of both artery and vein justifies im- 
mediate amputation. 

Delayed union, if the fragments are in a fairly good position and 
their mobility is not great, is best treated ordinarily by plaster-of- Paris 
encasement, including the pelvis, and by bearing some weight upon the 
limb with the support of crutches. I have seen union become solid as 
late as the sixth month. 

In failure of union, when the position of the fragments is bad and 
the mobility marked after three or four months, resection of the ends 
and readjustment are required. I have always made the incision on 
the outer side, cut the ends square, and kept them in contact by a 
suspended splint or by resting the limb upon an inclined support so 
that the leg and lower fragment would constantly press downward 
toward the upper one. Occasionally I have used plaster of Paris over 
the primarv dressing of the wound. For other details see Chapter 
VIII. 

3. FRACTURES AT THE LOWER END OF THE FEMUR. 

In this group are here included intercondyloid fractures, separation 
of the lower epiphysis, and fracture of either condyle. 

A. Intercondyloid Fractures. 

In these fractures both condyles are separated from the shaft and 
from each other, the line being T-shaped or Y-shaped. The fracture 
is sometimes classed as a supracondyloid fracture with splitting of the 
lower fragment, since that is thought to be the mode of production in 
most cases ; the shaft is first broken and then the upper fragment pene- 
trates and splits the lower (Fig. 218). The claim that the fracture id- 
ealised by a violence transmitted through the patella which acts as a 
wedge and splits off the condyles does not bear the test of experiment 
or harmonize with the fact that in a fall the blow is rarely received 



372 



FRACTURES. 



upon the patella. Trelat, l in an elaborate article in which it was first 
sought to give a detailed and full account of fracture of the lower end 
of the femur, points out that in six cases of supracondyloid fracture 
the average age was twenty-seven and a half years, while in thirteen 
cases of intercondyloid fracture it was forty-eight and a half years. 
The number of cases seems to me too small to warrant the inference 
that the difference is an essential and constant one. 

The main line of fracture across the shaft may be very oblique, as 
in the common fracture of the lower third, but is usually more nearly 
transverse in its general direction with splintering which makes the 
surface irregular, and lies close to the base of the condyles. 

The line between the condyles follows the intercondyloid notch, and 
is vertical and antero-posterior. In a case observed by Nelaton and 
reported by Trelat (loc. cit., p. 73), the mechanism of the separation of 
the condyles is shown plainly, the upper fragment being impacted into 
the lower one, but mainly on the inner side, and the separation of the 
condyles merely a fissure (Fig. 219). Usually, however, the condyles 
are completely detached from each other and sometimes separated far 
enough to allow the patella to sink in between them, and either may be 
further displaced backward than the other, with a corresponding rota- 
tion of the leg, since the tibia retains its connection with them. The 
crucial ligaments may be torn longitudinally or transversely, and then 
the attachment of the tibia is less close. 



Fig. 217. 



Fig. 218. 





Intercondyloid fracture of the femur. 
(Bryant.) 



Comminuted fracture of the femur, with 
splitting of the condyles. (Gurlt.) 



The injury is frequently compound, from within outward by the end 
of the upper fragment, especially when the fracture is oblique; danger- 
ous pressure by one or the other fragment upon the popliteal vessels is 



1 Trelat : Archives Generates de Med., 1851, vol. ii. p. 59. 



FRACTURES OF THE FEMUR. 



Fig. 219. 



not uncommon, and the vein and artery have been torn, the vein the 
more frequently. In one of my oases — fracture of both femurs by a 
fall of forty feet, the patient dying in thirty-six hours — one fracture 
was compound by perforation of the muscle and skin iu front by the 
upper fragment, the other was simple, but the popliteal vein was torn, 
and there was a large extravasation of blood in the thigh. In each 
the lower end of the upper fragment was very irregular, but not broken 
obliquely, and there was much comminution between it and the con- 
dyles ; the compact layer on the posterior face of the bone was pressed 
in toward the centre as if the lower fragment had been bent violently 
backward upon the other. 

The recognition of the main line of fracture is 
easy by attention to the usual signs ; that of the 
line between the condyles is made by noting the 
independent mobility of the two condyles on each 
other when they are grasped and moved backward 
and forward, and pain when they are pressed to- 
gether laterally. 

Shortening of the limb is common, but the sign 
is seldom needed for the diagnosis ; in an impacted 
fracture it might be useful in distinguishing the 
lesion from fracture of one condyle alone. 

Enlargement of the knee by separation of the 
condyles is rare, or at least is difficult of recogni- 
tion ; on the other hand, enlargement by effusion 
or hemorrhage into the joint is constant. 

Prognosis. The prognosis is serious as regards both the life of the 
patient and the integrity of the joint. Of 26 cases collected by Hen- 




Intercondyloid fracture 
of femur. 



Fig. 220. 




Plaster splints A is a wire attached for the purpose of suspension. 



nequin 7 died, 3 were amputated, and 1 6 recovered. The gravity of 
the injury depends mainly upon the implication of' the joint and the 



374 FRACTURES. 

traumatic arthritis excited thereby, which may easily end in suppura- 
tion and which in any case is very likely to result in more or less stiff- 
ness. 

Treatment. As the tendency to overriding and angular displacement 
(except when the main fracture is oblique) is not so marked as in the 
higher fractures, continuous traction need not be so vigorous or so pro- 
longed. I prefer the position of slight flexion of the knee and there- 
fore habitually use the Hodgen splint. Or the limb may be simply 
kept on a double inclined plane, or suspended by an anterior splint or 
a wire gutter, or encased in plaster or in plaster splints. 

Because of the length of the limb above the fracture and the more 
secure hold thereby given to a splint, the limb may be put in plaster or 
in splints and the patient allowed to leave the bed earlier than in other 
fractures of the shaft. 

Injury to the popliteal vessels may necessitate amputation. The 
indication is given by the appearance of gangrene of the leg or by 
direct recognition of the injury to the vessels. It may be proper at 
the beginning in a compound case to try to save the limb by ligature 
of the torn artery or by suturing the deep soft parts over the vein if 
that is only partly torn across ; if both are torn immediate amputation 
is justifiable. . 

B. Separation of the Epiphysis. 

Traumatic separation of the lower epiphysis of the femur is relatively 
frequent, and reports of cases, generally treated by operation, frequently 
appear. The first paper dealing specifically with separation of this 
epiphysis was a very complete one by Delens. 1 Later ones are by 
J. H. 'Packard, 2 J. Hutchinson, Jr., 3 R. H. Harte, 4 A. H. Meisenbach, 5 
McBurney, 6 and M. v. Brunn. 7 

Although the epiphysis may not unite with the shaft before the 
twenty-fifth year, in none of the reported cases has the patient been 
more than twenty years of age. 

Cause. The cause in almost all cases has been great violence, extend- 
ing or abducting the knee, and in a singularly large proportion of cases 
it has been the engagement of the leg between the spokes of a revolving 
wheel. In one or two cases the injury has been inflicted upon the 
infant during delivery by the feet and has then been attributed, but 
probably incorrectly, to direct traction. In a few cases the injury has 
been caused in attempts to straighten a stiff knee or in osteoclasis for 
deformity. 

Pathology. The separation, as is the rule also at other points, takes 
place between the conjugal cartilage and the diaphysis, is usually com- 
plete and clean, but sometimes leaves attached to the epiphysis one or 
more scales broken from the diaphysis or diverges to pass through a 

1 Delens : Archives Generates ds Medecine, 1884, vol. xiii. p. 272. 

2 Packard : Annals of Gynecology and Paediatry, November, 1890. 

3 Hutchinson : British Medical Journal, December, 1894, p. 671. 

4 Harte : Transactions A merican Surgical Association, 1895. 

5 Meisenbach : Medical Record, October 5, 1895. 

6 McBurney : Annals of Surgery, March, 1895. 

7 v. Brunn: Beitragezur klin. Chir.. vol. 52, p. 594. 



FRACTURES OF THE FEMUR. 



Fig. 221 



portion of the diaphysis. The periosteum is always freely stripped from 
the shaft, often for several inches, remaining attached to the epiphysis 
as an irregular sleeve. In a few cases the epiphysis has in addition 
been split longitudinally between the condyles. 

The common displacement is of the epiphysis forward and to one 
side, usually the inner, corresponding apparently to production by 
hyper-extension of the knee ; in other eases it has been to the inner or 
the outer side, doubtless when produced by abduction or adduction. 
When displaced forward it has also passed upward upon the anterior 
surface of the shaft with or without rotation (Plate XXXII. ). In a few 
cases it has been rotated about the vertical 
axis so that one condyle presented in the 
popliteal space, in others about a transverse 
axis so that the surface of separation was 
directed backward. 

The knee-joint is not often involved, but 
sometimes the capsule is torn and the joint 
filled with blood and exudate. 

In a large proportion of cases the injury 
has been compound, the lower end of the 
shaft projecting through the skin on the 
side or in the popliteal space. The pop- 
liteal vessels have been torn or, more fre- 
quently, so pressed upon that circulation 
was interrupted or seriously diminished. 
In one case a popliteal aneurism appeared 
several years later and was attributed to 
the accident. 

In some, even of the cases which were 
not compound, suppuration has ensued ; in 
others the pressure of the end of the frag- 
ment has caused the skin to slough, and in 
others gangrene of the leg followed. 

In a few cases of recovery without displacement arrest or diminution 
of growth has been observed. Puzey l noted in a lad sixteen years old 
at the time of the accident shortening of one inch three years later. 
In other cases examined with reference to this point growth has not 
been interfered with. 

Symptoms. Examination under anaesthesia should make it possible. 
unless the swelling is too great, to establish the identity of the two 
fragments and their relations to each other, to recognize that one is the 
lower end of the shaft and the other the epiphysis in normal relations 
with the tibia. This excludes dislocation ; and then the distinction 
between low fracture through the shaft and separation of the epiphysis 
is made by the character of the crepitus — bony in one ease, possibly car- 
tilaginous iu the other — the age of the patient, and the relations of 
the line of fracture to the adductor tubercle which lies immediately 
above the conjugal cartilage. 




Separation of the lower epiphysis 
of the femur. Incomplete displace- 
ment forward. (St. Bartholomew's 
Hospital, Poland.) 



1 Puzey: Liverpool Medico-Chirurgical Journal, January. 1S85, p. 41. 



376 FRACTURES. 

When the injury is compound the denudation of the shaft and 
the regular, slightly curved surface of its end demonstrate its char- 
acter. 

Rupture of, or pressure upon, the artery is shown by the absence of 
pulsation in the vessels below ; rupture of the vein might be suspected 
if the bleeding was profuse and venous, but could be demonstrated only 
by direct inspection. 

Treatment. The recorded cases show a very large proportion of am- 
putations, primary or secondary, and of deaths from shock, infection, 
and operation, but it seems reasonable to believe, especially in view of 
some of the later cases, that the future will show much better results. 
Patients have suffered in the past both from infection, which can now 
be more generally avoided, and from a consequent reluctance to take 
the chances of conservative treatment in compound injuries or to make 
an incision in the simple ones in order to effect reduction. Some of 
the amputations have clearly been justified, and will still be justified 
in similar cases, by the extent of the injury to the soft parts, but I 
feel sure that a much larger proportion of the compound injuries Avill 
be successfully treated with preservation of the limb, and of the simple 
ones with restoration of form and function. Dr. McBurney's two 
cases are particularly encouraging. 

If, in a simple case uncomplicated by injury to the vessels, complete 
reduction of the displacement cannot be made by traction and manip- 
ulation, it would be not only proper, but, I think, imperative, to expose 
the fracture by a longitudinal incision, preferably on the outer side in 
front of the tendon of the biceps, in order to overcome the obstacle, 
which would doubtless be the interposed periosteum and perhaps some 
muscular bundles. Schuchardt - 1 reports a successful case, and I have 
had one. 

In a compound case free enlargement of the wound in the skin and 
fascia would probably make reduction possible without the aid of resec- 
tion of the end of the shaft. If the injury to the vessels is such that 
the vitality of the limb cannot be preserved, amputation must be done, 
and it should be as low as the condition of the soft parts will permit, 
that is, through or a short distance above the fracture. It seems even 
possible that in some cases the amputation might be done a short dis- 
tance below the knee so as to preserve that joint to the patient. 

Hutchinson advises that the limb should be immobilized in full 
flexion after reduction, on the theory that the pressure of the quad- 
riceps in that position would keep the fragment securely in place. I 
doubt if there is enough tendency to displacement to justify so irksome 
an attitude. 

C. Fracture of Either Condyle. 

Fracture of a single condyle may be caused by direct violence, as in 
a fall upon the bent knee, or by avulsion, the force being exerted 
through one of the lateral ligaments to tear off one condjde by 

1 Schuchardt : Beilage zum Centralblatt fur Chirurgie, 1901, p. 146. 



FRACTURES OF TJfE E EM 111. 



.>( i 



bending the leg toward the opposite side, or by the direct pressure of 
the head of the tibia against the condyle on the side toward which the 
leg is bent. In a case reported by A. H. Crosby 1 the fracture was 
caused by a twist of the leg while the patient, a youth of twenty-one 
years, was resting his entire weight upon it. 

The specimens of fracture of a single condyle are not numerous, but 
they show that the line may run for a considerable distance upward 
from the intercondyloid notch so that the fragment terminates above in 
a long point, or it may turn abruptly above the edge of the articular 
cartilage toward the side of the bone, as in Fig. 222. A unique case 
of fracture of the posterior portion of the external condyle was reported 
by Braun.' 

The fragment may be displaced upward, or to one side, or it may be 
swung around so as to lie partly behind or partly in front of the femur, 
usually the former. As it remains attached to 
the tibia the first and third displacements are 
indicated by the posture of the leg, the second, 
which is very rare, by the greater breadth of the 
knee. 

As the displacement is usually slight, and the 
connections untorn, the injury may easily be over- 
looked, or, if suspected, not recognized with cer- 
tainty. In a case under the care of Gosselin 
(quoted by Trelat) the patient was treated for 
more than a month for a supposed arthritis of the 
knee ; he grew weaker daily and died of exhaus- 
tion. At the autopsy the joint was found full of 
pus and one of the condyles broken. The frag- 
ments were in exact apposition, but there was no 
sign of repair. The diagnosis must be made upon 
the localized pain, ecchymosis, loss of function, 
and abnormal mobility and crepitus, recognized 
by direct manipulation of the condyle or by 
moving the leg laterally or in the direction of 
flexion and extension. 

The reported cases show a remarkable variety in their course and 
terminations. Some patients have recovered without greater reaction 
than would be expected after a simple non-articular fracture ; in others 
the joint has suppurated, and the case has terminated fatally ; in Dr. 
Crosby's case the fragment was removed six months afterward, by 
operation, and the patient made a complete recovery ; and in a case 
first seen by Hamilton three months after the injury, the fragment 
remained ununited and could be moved upward half an inch with dis- 
tinct crepitus and pain by flexing the knee. During the next two years 
the usefulness of the limb increased steadily. 

Treatment. The treatment consists in reduction of such displacement 
as may exist by acting upon the fragment through the lateral ligament 

1 Crosby : New Hampshire Journal of Medicine, 1S57. 
-Braun: Arch. fur. klin. Chir., vol. 42, p. 108. 




Fracture of the internal 
condyle of the femur. 



37S 



FRACTURES. 



Fig. 223. 



and the leg, and prevention of its recurrence by keeping the leg fixed 
in the position to which it lias been brought in making the reduction. 
As the lateral ligaments are tense when the knee is extended, and relaxed 
when it is flexed, the extended position is the one which gives most 
security. The objection urged by Malgaigne, that it favors anchylosis, 
is, I think, unfounded; we know that the common cause of anchylosis 
lies in the severity or the prolongation of an arthritis, not in the posi- 
tion in which the joint is kept. In the flexed position of the knee a 
slight displacement upward of the fragment could occur easily, and it 
would certainly pass unrecognized so long as the position was kept, 
and would show itself in abduction or adduction of the leg as soon as 
it was extended. I prefer, therefore, to treat a case in the extended 
position upon a posterior splint or in a plaster bandage. After three 
or four weeks the knee may be partly flexed if the fragment has lost 
its mobility. 

Massage is useful to shorten the period of convalescence and hasten 
the restoration of function. Incision of the joint for the removal of 
a large amount of blood from it could probably be safely done and 
would diminish the chance of limitation of motion. 

D. Fracture of the Internal Epicondyle. 

This injury was first described by Stieda x on the basis of four cases 
observed by himself. Vogel 2 reported five cases. In addition to the 

clinical history there are the #-ray find- 
ings in most of the cases and a fragment 
removed by Yogel in one. 

The injury appears to be the breaking 
off of a scale of bone about half an inch in 
diameter from the side of the condyle at 
a point corresponding to the insertion of 
the inner head of the gastrocnemius and 
the adductor. In most of the cases a 
blow had been received upon the side of 
the knee. It is uncertain whether the 
fracture is caused by a direct blow or by 
avulsion through the attached muscles, 
but the former is thought probable. The 
attachment of the internal lateral ligra- 
ment is not concerned, for it lies a little 
below the part involved. In all the cases 
the immediate reaction was quite sharp, 
*vc>t,^^ + v^- * ^ , the patient being disabled for at least a 

-bractureof the internal epicondyle r . , & 

of the femur. (Stieda.) IOrtmght. 

In two of the cases the fragment ap- 
peared to have reunited. Under the arrays the fragment appeared as a 
somewhat crescentic shadow separated one or two mm. from the condvle. 
There was local pain on pressure, an effusion in the joint, no pain on 
abduction or adduction of the leg. 

i Stieda : Arch, fur klin. Chir., 1908, vol. 85, p. 814. a Vogel : Ibid., vol. 89, p. 1076. 




CHAPTER XXIV. 

FRACTURES OF THE PATELLA. 

According to published records fractures of the patella represent 
from one to two per cent, of all fractures. They are much more fre- 
quent in men than in women, and in middle life than in childhood or 
old age. The youngest of Malgaigne's patients was eleven years old, 
and he knew of no other younger than seventeen years. The youngest 
patient in the 127 cases collected by Hamilton was live years old, and 
the fracture was very different from the usual one since only a small 
piece was broken from the margin of the bone by a direct blow; his 
next youngest case was sixteen years old, and in this also the fracture 
was by direct violence. Dittmer 1 reports one in a boy nine years old. 

Causes. 

The cause may be direct or indirect, a blow or fall upon the patella 
or the sudden vigorous contraction of the quadriceps femoris, or 
the sudden flexing of the knee against the opposition of the quadri- 
ceps. The statistics that have been collected to show the relative fre- 
quency of these varieties vary widely and are, I think, untrustworthy 
because of the difficulty, or rather the impossibility, in many cases of 
recognizing the mode in which the fracture has been produced. The 
patient slips or stumbles, makes an effort to save himself, falls, and 
the patella is found to be broken. He is unable to say whether he 
struck upon the patella or upon the tuberosity of the tibia, whether 
directly in front or upon the side, or, and this I have often met with, 
he asserts that he fell upon the patella because he knows it is broken, 
and cannot understand that the lesion could have been produced in any 
other way. If the examination is pushed, and the question asked, " How 
do you know it ? " the answer is often, " Why, it must have been so." 

My own conviction is that the efficient agent in the great majority 
of cases is the contraction of the quadriceps, either directly or by the 
forced flexion of the knee against its opposition, and the grounds for 
this belief are the numerous cases in which this mode of production 
can be clearly demonstrated, the practical impossibility of producing 
any but a comminuted fracture experimentally by direct violence, and 
the position of the patella, which is such that the blow is rarely 
received upon it in a fall. 

The question whether muscular contraction breaks it by direct trac- 
tion or by bending it over the convexity of the condyles is of purely 
academical interest, and in most cases it cannot be answered positively 
because the position of the bone at the moment of fracture with refer- 
ence to the condyles cannot be known. In a few eases the fracture has 
been caused, beyond question, by simple traction without bending or 
cross-strain, as in a ease reported by Garreau 2 in which a second frac- 

1 Dittmer: Langenbeck's Archives, vol. Hi. 'Garrean : Revue M6dico-Chiruig., is.">:?. p, 375. 

379 



380 



FRACTURES. 



ture by muscular action occurred in the upper fragment twelve years 
after the first fracture had healed with a separation of four centimetres 
(If inches). In others it is equally certain that the traction of the liga- 
mentum pate 1 la? was inclined somewhat backward from the long axis of 
the patella, the fracture taking place when the limb was partly flexed. 

The common clinical form is a vigorous contraction of the quadri- 
ceps, either simply in voluntary use of the limb or aided by forced 
flexion of the knee by forces which overcome the opposition of the 
muscles. Thus, a man jumps and breaks the patella, or he fails in an 
effort to avoid a fall and the leg is bent under him, or, as in a case of 
my own, he seeks to push a heavy box with his foot resting against its 
side and the knee partly flexed, the foot slips down, the flexion of the 
knee is sharply increased thereby, and the bone is broken. This forcible 
flexion is a frequent cause of early refracture while motion is still 
limited and the descent of the upper fragment prevented by adhesions 
or peri-articular thickening. 

In a few cases there is reason to think that a blow upon the bone 
has cracked it or originated some process in it by which its complete 
fracture by muscular action shortly afterward was made easy. 

Pathology. 

In the great majority of cases by indirect violence the fracture is 
transverse or slightly oblique, and usually at or just below the middle 



Fig. 224. 



Fig. 225. 




Unusual form of fracture of patella. 
B, mesial section. 



anterior surface ; 



Comminuted fracture of the 
patella. Bony union. Exuber- 
ant callus at several points. 

(GURLT.) 



of the bone ; sometimes it lies very near one end of the bone, espe- 
cially the lower, and once or twice I have seen it crossing and separating 
only the upper inner corner. Hoffa l saw a fracture of a small piece of 
the* outer border by muscular action. I have occasionally seen the 
lower fragment split longitudinally, and I have seen one case (Fig. 224) 
in which on inspection through an incision the surface of fracture was 
found to be very oblique downward and backward and was also curved 
downward on the anterior aspect. Parke 2 reports a somewhat similar 
one seen two months after the accident ; the injury was apparently 
caused by direct lateral pressure, and the upper and posterior fragment, 
comprising nearly half the bone, lay wholly above the other. 

1 Hoffa : Deutsche Med. Wochenschrift, Ver Beil, 1903, p. 111. 

2 Parke: New York Medical Journal, March, 1893, p. 303. 



PLATE XXXVI 




Fig. 1 — Fracture of Patella, five months old; after treatment by straight splint. 
Active extension almost complete 




Fig. 2, —Fracture of Patella; two years after mediate suture 



> 

X 
X 
X 

w 

<! 
•J 
0< 





PLATE XXXVIH 




Fracture of Patella. Ossification of upper portion of 
ligamentum patellae. 



FRACTURES OF THE PATELLA. 381 

A unique case of fracture in the frontal plane — anterior and posterior 
fragments — with outward dislocation of the posterior piece, is reported 
by Kroner in Cntralblatt fur Chir., 1904, p. 1469. He thought the 
dislocation preceded the fracture. 

Vertical, comminuted, and some oblique fractures are due to direct 
violence, and rarely show much displacement. 

The displacement after transverse fracture is ordinarily well marked, 
its degree being modified by the extent to which the periosteum and 
lateral expansions are torn. Occasionally there is none. The separa- 
tion, which may be an inch or more, is due in part to the retraction 
of the quadriceps and the tension of the fascia lata and in part to dis- 
tention of the joint by blood and exudate. While the injury is fresh 
the quadriceps, even when actively contracted, can rarely separate the 
fragments for more than a short distance when the knee is fully ex- 
tended and the hip somewhat flexed. Later, if the fragments remain 
ununited, the gradual shortening of the muscles increases the interval. 

A third cause, which acts less promptly, is the gradual retraction 
of the ligamentum patella?; in one of MalgaigneV old cases it w r as 
shortened one-half, measuring only three centimetres, and in one 
reported by Brunner 2 it was shortened from five and a half to one and 
a half centimetres. 

Occasionally the lower fragment is so rotated that its fractured sur- 
face is directed forward. 

The other displacements are more readily recognizable later. They 
are lateral displacement and angular displacement, the angle pointing 
forward, backward, or to one side. Lateral angular displacement 
appears to be commonly the result of uneven stretching of the fibrous 
union after the patient begins to use the limb; anterior angular dis- 
placement is not only produced by the pressure of pads or bandages 
above and below the fragments when the latter are in contact, or 
nearly so, but it is also the inevitable effect of separation by distention 
of the joint, and may apparently be caused by cicatricial retraction of 
the lateral soft parts. I have seen in a skiagram the upper fragment 
turned so that its fractured surface was directed backward. (Plate 
XXX VL, %. 1.) 

The associated injuries to the soft parts have become well known 
through the opportunities for direct inspection furnished by frequent 
resort of late to open arthrotomy in treatment. They involve the 
fibro-periosteal envelope of the front of the bone, the lateral expan- 
sions and capsule on the sides, and the fascial expansions downward. 

The fibro-periosteal layer on the front of the bone is usually torn 
at a level different in part from that of the fracture and rather irregu- 
larly, so that it projects from the edge of one or the other fragment, 
usually the upper, as a ragged fringe, sometimes fully half an inch 
wide, which drops over the fractured surface and is thus interposed 
between the fragments when they are brought together. Macewen was 
the first to call special attention to this fringe and to suggest that it 
might be a bar to close, firm union. It is sometimes notably supple- 
mented by one or more long strips of fascia (1 have seen them more 

1 Malgaigne: Atlas. Plate xiw. Fig. 1. and j>. IT. 

2 Brunner: Deutsche med. Wochenschrift. May 17, 1888. 



382 



FRACTURES. 



than four inches long) attached to the upper fragment and drawn up 
from the region immediately below, lying curled up in the joint between 
the fragments. The lateral expansions and the capsule are freely torn 
on each side transversely, except in the rare cases without separation. 
The fracture may be made compound by direct violence or by tear- 
ing of the skin in the separation of the fragments when it has become 
adherent to the patella by an inflammatory or cicatricial process/ The 
common instances of the latter are in refracture, especially after opera- 
tive treatment of the first fracture; much more rarely in a primary 
fracture after a wound of the skin which has not entirely healed. 



Symptoms. 

In fractures by muscular action, with or without a fall, a sharp 
crack may be heard and the patient is usually unable to use his limb. 
In a few cases he has walked, and, indeed, in most it is possible to 
walk backward, keeping the knee extended by the pressure of the heel 
on the ground, or even to walk forward if the uninjured limb is 
advanced and the other swung up to it but not beyond it. 

The knee becomes promptly swollen by an effusion of blood or 
synovia into it and by tumefaction of the soft parts, especially if a blow 
has been received upon it, and the two fragments, separated usually 
by a well-marked interval, can be made out and their independent 
mobility recognized. This mobility may be very slight if the frag- 
ments are close together. Crepitus can often be felt when the frag- 
ments are pressed together. 

The subjective symptoms are moderate pain when the limb is at 
rest, increased by movement and by pressing the fragments together 
and by pressure along the edge of a fragment, and 
inability actively to extend the leg or to raise the 
heel from the bed. It must be remembered that 
in rare, entirely exceptional, cases the fibrous cov- 
ering of the bone may remain untorn and consti- 
tute a sufficient connection between the fragments 
to make a limited use of the limb possible. 

In vertical or comminuted fractures the signs 
recognized by palpation will vary in accordance 
with the differences in the lines of the fracture, 
and in the former active extension will be pre- 
vented only by the pain attending the effort. 

Course and Termination. 

The region swells promptly, partly by reaction 
of the overlying soft parts, partly by the disten- 
tion of the joint by blood and synovia; the 
swelling can be largely prevented or rapidly re- 
duced by methodical pressure, preferably by an 
elastic bandage. 

If the fragments are kept fairly well together and if neither is tilted 
a fibrous bond forms between them which may ossify wholly or in 




Bony union after frac- 
ture of the patella. (Spec- 
imen 201 of the Mus£e 
Dupuytren.) 



FRACTURES OF THE PATELLA. 



383 



part if the contact is very exact (Fig. 226 and Plate XXXVI. and 
XXXVII.), but which in cases not treated by operation almost always 
remains fibrous and usually lengthens somewhat under use during the 
first few months. Even in some operative cases which have again 
come to direct inspection after many months, the union which was so 
close that no independent mobility could be recognized has been found 
to be fibrous. Some of the skiagrams I have taken have shown bony 
union only in the posterior half or three-fourths. They also show an 
angular displacement producing a slight concavity of the articular 
surface which, according to Chaput, 1 favors full restoration of func- 
tion. If the fragments are not kept together, or if one is turned so 



Fig. 228. 



Fig. 229. 




Fibrous union with great 
separation, after fracture 
of the patella. The band 
adheres to the broken sur- 
face of the lower fragment. 
(Holmes's System.) 







Hypertrophy of patella after fracture 
and wiring. 



that its fractured surface is directed forward or backward, the union 
between them is by a bond formed mainly by the overlying soft parts 
(Fig. 227), but sometimes by a thicker one apparently of new forma- 
tion (Fig. 228); it seems probable that the latter form is produced by 
the elongation of a shorter bond formed under favorable conditions of 
proximity and position. 

Hypertrophy of the fragments is frequently noticed and sometimes 
appears mechanically to limit flexion of the knee : occasionally also 
bony nodules, sometimes quite large, form within the connecting band. 



1 Chaput: These de Paris, 1885, and Hull, de la Soc. Anal.. April. 1888, p. 459. 



384 



FRACTURES. 



Once I found ossification of the upper half of the ligamentum patellae. 
(Plate XXXVIII.) 

On the first attempts to use the limb, whether these are made promptly 
or only after a month or two, the joint is found to be very stiff, but 
usually the range increases quite rapidly and full active flexion and 
extension are ultimately re-established. In a certain, not large, pro- 
portion of cases there is notable loss of function : either inability fully 
to flex, or almost complete loss of active extension although the joint 
is freely movable, or inability to make complete active extension, the 
limb remaining slightly flexed. 

These disabilities coincide with and presumably depend upon the 
varying conditions of the fragments and uniting bond which have been 
described. 

Inability to flex appears to be largely due to retraction of the portion 
of the capsule attached to the upper fragment and of the fascia lata on 
the outer side, especially of the upper side of the rent in the lateral 
expansion, and sometimes to enlargement of the patella, itself the 
result of hypertrophy of the fragments or of a short stiff bond between 
them which makes the bone too long to turn over the curve of the 
condyles. Retraction of the quadriceps seems not to be an important 
factor in this disability. (See also the section on Disability After 
Fracture.) 

Loss of active extension, when marked and when combined with 
free flexion, is due to insufficient union between the fragments and the 
absence of complementary fascial connections between the quadriceps 

Fig. 230. 




Extreme separation of the fragments after fracture of the patella. 

and the leg, such as are found in some cases. It is most marked when 
the fracture is in the lower half of the bone, because of the loss of the 
lower fibres of the vasti. It is remarkable that this loss interferes so 
slightly with ordinary use of the limb in most cases ; the patients often 
walk easily and securely, although they are exposed to fall whenever 
their weight rests only on the partly flexed limb. They seem instinc- 



FRACTURES OF THE PATELLA. 385 

tively to depend upon the sound limb whenever the use of the damaged 
one would be unsafe. There is difficulty in going up and down stairs 
and in rising from a seat. In the case represented in Fig. 230 the 
patient claimed not to be aware of any noteworthy defect in the limb 
although active extension was almost entirely absent. 

The common defect is slight limitation of active extension, the 
patient being unable to raise the heel from the bed without first 
slightly flexing the knee. 

Degeneration of the quadriceps in direct consequence of the trauma 
has been alleged as a cause of diminution of the power of active exten- 
sion, and has been used as an argument for early resort to massage. 

Eupture of the uniting band or bone (" refracture ")is not infrequent 
in the first few months, or even much later when flexion has remained 
limited. The cause is forcible flexion of the knee beyond the range 
that has been acquired, as in a fall ; it has occasionally been caused 
by the surgeon in an attempt to increase the range by passive 
motion. The mechanism is the pulling away of the lower fragment, 
the corresponding descent of the upper being prevented by the pre- 
viously mentioned conditions. Occasionally the soft parts, including 
the skin, have been so adherent that the rupture has involved them 
also, thus freely opening the joint. In the past such an accident was 
frequently followed by suppuration of the joint and the consequent 
loss of limb or life. This complication is more likely to happen when 
the skin over the fracture has been transversely incised in operative 
treatment. 

Fracture of a fragment has occurred in a few cases. 

The course of a compound fracture depends on the occurrence or 
avoidance of infection ; if "it is avoided the course and termination are 
practically those of simple fracture ; if it occurs it creates serious risk 
to life and limb, leading to anchylosis or amputation. 

Treatment. 

The obstacles to apposition of the fragments and their close reunion 
are the pull of the quadriceps, the distention of the joint, and the inter- 
position of the fibro-periosteal fringe or aponeurotic shreds. Later 
causes of limitation of function are adhesions and retraction of the soft 
parts of the joint, hypertrophy of the fragments, and possibly degene- 
ration of the quadriceps. 

The numerous methods of treatment, which respectively seek more 
or less specifically to remove one or another obstacle or late conse- 
quence, may be grouped as operative and non-operative, including in the 
former those in which the fragments are mechanically fastened together 
either after open arthrotomy or by means introduced subcutaneouslv or 
acting temporarily or permanently through the punctured skin ; in 
short, those which distinctly involve the chance of infection of the joint. 

The points to be considered in choosing between these two main 
methods are that a long experience has shown that non-operative 
methods furnish in the great majority of cases in which they are prop- 
erly used a result which is functionally satisfactory even if the union 
25 



386 FRACTURES. 

of the fragments is not close, that most of the failures are apparently 
due to unfitness of the method chosen or its faulty use, that only in a 
small proportion of cases are the conditions such as to make a bad 
result inevitable without resort to operative methods, and that most of 
the later causes of limitation of function are equally active after either 
method of treatment. That direct mechanical approximation and 
maintenance of the fragments, if the dangers of the operation are 
escaped, practically annuls or ensures the removal of the primary 
obstacles in all cases, notably hastens the restoration of function, and 
probably makes that restoration more complete in some cases, besides 
making it possible in those in which otherwise it would certainly fail 
to be obtained, cannot be denied. On the other hand, operation exposes 
to infection ; and if infection occurs the result is almost certain to be a 
stiff joint, amputation, or death. In short, it takes less time and makes 
a good result more certain, but some of its failures are disastrous to an 
extent for beyond that of non-operative failures. 

If there was no risk in an open operation it would deserve selection 
in almost every case, if only because it makes possible the removal of 
those certain causes of failure which are sometimes present and cannot 
otherwise be recognized and removed, such as tilting of the fragments 
and the interposition of bundles of fascia. The propriety of resort to 
operation turns, therefore, in the absence of special reasons, upon the 
measure of safety with which it can be done, and while I believe that 
certain methods, when surrounded by every precaution, can be em- 
ployed with an assurance of success that justifies resort to them, and 
while I habitually use them, yet I have never taught them as routine 
practice, but on the contrary have strongly advised against their use 
except by those who can bring to them not merely experience in oper- 
ating but also the habit of taking surgical precautions and the aid of 
trained assistants who have the same habit, who are practising those 
precautions daily ; in short, the personnel of an active surgical hospital 
service. I do not mean that any one of the many operative methods 
proposed and used can be done with this assurance of success, but only 
that the one with which I am familiar, and which now (February, 
1909) I have used in fully two hundred and fifty cases without acci- 
dent, can be so done, and that only because it is freer than most opera- 
tions from those more or less unavoidable causes to which we attribute 
our disasters. I refer especially to the difficulty of making the hands 
clean. The general practitioner, and even the occasional surgeon, is not 
only fully justified in using a non-operative method but ought to do so ; 
and he can feel assured that the methods at his command justify the 
expectation of a satisfactory, even if not perfect, result. 

1. Non-operative Treatment. The opposing factors specially sought 
to be controlled by most of the methods are the effusion in the joint 
and the action of the quadriceps to create or maintain separation. 

The production of the effusion may be opposed by systematic press- 
ure or cold ; its absorption may be hastened by pressure or massage, or 
it may be immediately removed by puncture or aspiration. I prefer 
pressure with a light rubber bandage ; this will remove the effusion 
rapidly or, if the case is seen early, will notably limit its production. 



FRACTURES OF THE PATELLA. 



:J87 



Immediate removal of the effusion by aspiration or puncture, with 
or without washing of the joint, is occasionally practised, hut, except 
in rare conditions such as a large intra-articular hsematoma, has no 



Fig. 231. 




Dressing for fracture of the patella. The final turns of the roller in front of the knee are not 

shown in the cut. 



marked superiority over the slower removal by pressure. If washing 
is done it should be with a hot sterile salt solution, not with carbolic 
acid. 

After removal, immediate or gradual, recurrence must be opposed 
by bandaging ; the application of strips of adhesive plaster so as 
entirely to cover the front and sides of the joint has been recom- 
mended, but a well-applied roller is probably equally efficient. 

Approximation of the fragments is effected by the hands, and its 
maintenance by a great variety of devices from a simple circular 
bandage to complex apparatus. AH are combined with a posterior 
splint for immobilization and usually with confinement to the bed with 
the foot raised for at least a month. As for active separation of the 
fragments by the quadriceps, full extension of the knee with elevation 
of the foot (flexion of the hip) prevents it. 

The simplest form is a roller-bandage applied over a long straight 
or, better, a moulded posterior splint, the turns immediately above and 
below the fragments being placed obliquely, as shown in Fig. 231. 
Fixation has been sought in encasement in plaster of Paris by pressing 
the still soft dressing snugly down above and below the fragments and 
maintaining the pressure until the dressing has hardened, but an irre- 
movable dressing wdiich prevents inspection exposes to rude disappoint- 
ment on its removal, for as the limb grows loose within the control of 
the fragments is lost and separation may occur and remain unrecog- 
nized until it is too late to remedy it. 

More exact fixation of the upper fragment has been sought by fixed 
or elastic traction on the skin close above it, so applied that its pressure 
will be downward and backward and thus act upon the fragment. 
Thus, a strip of adhesive plaster an inch or two wide is laid across 
close above the fragment and its ends carried downward on either side 
to the sides or back of the splint at the calf, as in Fig. 232, For 
a number of years I used this plan, sometimes with a piece oi" rubber 
tubing interposed on each side to make the traction elastic, and was 



388 



FRACTURES. 



well satisfied with the results. 
U-shape that it may fit better. 



Sometimes the plaster is cut in a broad 



Fig. 232. 




Fracture of the patella 



Massage has been strongly recommended to reduce the swelling, pre- 
vent adhesions, diminish retraction of the capsule, regenerate the quad- 
riceps, and hasten convalescence. It has even been claimed that it 
could be trusted to secure a good result without immobilization of the 
joint or confinement to bed, but even its most ardent recent advocates 
have not repeated the claim. I do not think it removes the effusion as 
rapidly and conveniently as elastic pressure does ; after the second or 
third week it hastens absorption of the exudate and improves the 
circulation as after other injuries, but I doubt if it does more than 
somewhat shorten the period of convalescence. 

In most fractures by direct violence the preservation of much of the 
periosteal envelope prevents separation, and no special measures are 
required to keep the fragments together. 

Thomas 1 reports eleven cases to prove that an excellent result can be 
easily obtained without confinement to bed. He simply immobilizes 
the joint by the splint which he uses in disease of the knee, two metal 
rods lying on either side, attached to the heel of the shoe, and fitted 
with a perineal band and three straps, one each behind the knee and 
across the front of the thigh and leg. It is worn for four or five months. 

To summarize : an elastic bandage covering the patella and six inches 
above and below may be applied for a few days to reduce or prevent 
swelling, and if it keeps the fragments well together it may be con- 
tinued for a fortnight. Then the limb is placed in a long posterior 
plaster gutter or on a straight posterior splint and bandaged from the 
foot to the upper part of the thigh, the turns immediately above and 
below the fragments being placed obliquely as above shown, and the 
patient is kept in bed on his back with his foot well raised. A month 
or six weeks after the accident the limb is encased in plaster and the 
patient allowed to go about on crutches. If the attention can be given, 
the splint may be cut open in front and removed daily for massage, and 
after a month it may be left off at night and then in the house during 
the day, and the patient encouraged to move the joint. The danger to 
be avoided is premature forcible flexion of the knee, which is most 
likely to happen by accident, as in a fall ; the prolonged use of the 
splint is mainly as a protection against this accident. The closer the 



Thomas : Provinc. Medical Journal, August 1, 




FRACTURES OF THE PATELLA. 389 

union the shorter the time it needs to he worn, but certainly no great 
strain should be put upon the bond until after the second month. 

A few methods, which may be termed intermediate between the 
operative and non-operative, have been devised to act directly upon 
the fragments without the necessity of opening the joint, but as they 
require multiple punctures of the skin which must be kept open for 
several weeks, and as these punctures 

may communicate with the seat of Fig. 233 - 

fracture through the spaces created 
by the extravasated blood, the chance 
of infection exists as in open opera- 
tion, while the work is done less 
easily and effectively. 

Maigaigne's hooks (Fig. 233), the 
earliest of these, may be taken as the 
type. The points of the hooks are Maigaigne's hooks. 

passed through the skin and engaged 

respectively in the upper and lower ends of the patella, and then 
brought together by the screw until the fragments are coaptated. It 
is an efficient method and is usually well borne, but the presence of 
swelling may make the application difficult or impossible. They must 
be worn three or four weeks. The danger is of suppuration about the 
points and of its possible extension to the joint. The instrument has 
been modified by Levis — two separate pairs instead of a double one — 
by W. K. Otis, who made the individual parts adjustable, and by 
Duplay, who made it stronger and firmer. It has furnished many good 
results, and the accidents following its use have been few. Of course 
the punctures must be carefully protected. To avoid making punctures 
in the skin Trelat used two gutta-percha plates moulded to the surface 
above and below and engaged the hooks in them. 

I devised and tried in a few cases l a modification consisting of a 
two-pronged fork bent on the flat, which was engaged in the upper 
fragment with its shank resting on the thigh above, and was drawn 
downward by an elastic cord. It is easier of adjustment than Mai- 
gaigne's hooks and did the work equally well, but suppuration about 
the points was occasionally free. I long ago abandoned it for the 
suture. 

Mayo Robson 2 passed a steel pin transversely through the tendon of 
the quadriceps close to the upper edge of the patella, and another 
through the ligamentum patella? close to the lower edge, and then drew 
the fragments together and maintained them by a ligature about the 
projecting portions of the pins on each side. I should think it an 
easier method than Maigaigne's. Dieffenbach had long before driven 
pegs into the fragments and tied them together. 

Anderson 3 modified Robson's method by passing the pins through the 
fibro-periosteal covering of the fragments, a disadvantageous change, 
I should think, because it brings the punctures nearer the fracture and 

1 Stirason: New York Medical Journal. January :i. 1885, p. 23. 

2 Robson : British Medical Journal, March 30, 1889. 

3 Anderson : Lancet, July 2. 1892. 



390 FRACTURES. 

thereby increases the chance of infection of the joint in case suppura- 
tion should take place about the pins, as it did in one of his four cases. 

Certain other methods of subcutaneous or temporary fixation which 
resemble the above in some respects will be mentioned in the next 
section because in all the joint is opened, directly or indirectly, through 
the gap made by the fracture, and as therefore direct and early infec- 
tion is possible they should be compared with others carrying the same 
risk. 

2. Operative Treatment. This, which began, 1 in the antiseptic 
period, with Lister's exposure of the fracture and wiring of the frag- 
ments, presents a great number of methods and procedures, some of 
which are a natural evolution from their predecessors in the direction 
of simplicity, efficiency, or safety, while others are merely novelties 
obtained at the price of some disadvantage or based upon the exag- 
geration of the importance of some indication. The fundamental idea 
is the mechanical fixation of the fragments by some form of suture, 
and the associated one is either the removal of the effusion or of the 
interposed periosteal fringe, or the reduction of the risk by the use of 
punctures instead of a free incision. Their comparison will be made 
easier by first considering certain facts and general principles. 

The pull of the quadriceps when the knee is fully extended and the 
hip slightly flexed is so weak that even when the muscle is actively 
contracted it will not separate the fragments more than half an inch. 
I have repeatedly observed this during an open arthrotomy, and I 
have seen several patients pass through an attack of delirium tremens 
in the first week without tearing apart the fragments although they 
were fastened together only by catgut or light silk sutures. It is plain, 
therefore, that a strong suture, one of metal or heavy silk, is not neces- 
sary to the proper approximation of the fragments if the joint is not 
distended and if the foot is kept elevated. Consequently, any addi- 
tional risk or complexity of procedure involved in the use of a strong 
suture is not justified. This, in my opinion, is sufficient for the rejec- 
tion of all methods of suturing which require drilling of the bone, 
even without consideration of the other disadvantages of a permanent 
suture through it which have been described in Chapter VII. 

The removal of the effusion facilitates approximation, reduces ten- 
sion, and probably diminishes the chance of the formation of adhesions 
and peri-articular thickening and retraction. Other things being equal, 
therefore, methods which include such removal are preferable to those 
which do not, and if they also permit the adjustment of an interposed 
periosteal fringe or aponeurotic shred they have an additional advan- 
tage. 

The periosteal fringe, long charged with much of the responsibility 
for failure of bony or close fibrous union, has been shown by large 
experience with operative methods in which it was disregarded to be 
usually a negligible factor ; that is, long series of cases treated by sub- 
cutaneous suture have given close union in almost all, and yet it must 
be believed that a fringe of some size was present in most of them. 

1 In 1534 Dr. Barton, of Philadelphia, fastened the fragments together by a wire passed 
through them and knotted outside the skin ; the patient died. 



FRACTURES OF THE PATELLA. 39] 

On the other hand, I think the large aponeurotic shreds which I have 
seen several times would probably have been a serious obstacle if they 
had been left, and possibly similar ones have been responsible for some 
of the failures noted under methods of treatment usually efficient. It 
is, therefore, not necessary to choose an open method of operating in 
order to adjust the fringe, but probably in a small proportion of cases 
there is present a fringe or shred of such size that it will diminish the 
success of any operation which does not effect its removal. Again, 
other things being equal, an open method better protects against this 
obstacle to success. 

Infection may occur in any operation which wounds the skin, and 
the chance of its spread to the joint — the great danger — is greater if 
that wound communicates with the joint or the seat of fracture. The 
briefer the existence of that wound or of that connection, the less the 
danger. All the so-called subcutaneous methods require two or more 
small incisions, and in all a suture of silk or wire is passed either 
directly into the joint or through the line of fracture or its immediate 
neighborhood. If suppuration occurs at a puncture the suture opens 
a direct road for its spread to the joint. The size of the wound is not 
a measure of the chance of infection , that comes, if the common pre- 
cautions are taken, mainly from the hands of the operator and his 
assistants. 

Finally, the permanent presence in the tissues of a foreign body is 
not, according to general experience, a matter of indifference ; occasion- 
ally suppuration takes place about it after a long interval, and not 
infrequently its removal has been required because of pain and irrita- 
tion. 

The operative methods are : (1) by open incision — direct suture of 
the fragments through holes drilled in them, suture of the fibro-perios- 
teal layer and capsule, and mediate suture through the tendon of the 
quadriceps and ligamentum patellae ; (2) subcutaneous suture — by wire 
through the whole length of the fragments, or by silk through the 
tendons and crossing the front of the bone ; (3) subcutaneous permanent 
ligature surrounding the fragments in the sagittal plane and lying 
partly in the joint ; (4) temporary ligatures passing through the joint 
as in (3), or through the tendons as in (2), or through the bone, all tied 
outside the skin. 

The methods are far too numerous to permit a detailed description 
and criticism, even if it were not probable that most of them will be 
abandoned in favor of the simpler and safer ones. Many of them, too. 
can be judged in classes. Thus, for reasons given above, I would reject 
all in which a permanent suture is placed in the bone itself. 

Temporary ligature through the tendons (one of the earliest methods 
proposed), or through the bone, or around it through the joint seems 
to me to be more dangerous, because of the prolonged communication 
with the exterior, and less efficient than the similar subcutaneous 
methods. 

The subcutaneous methods which can be done equally well by an 
open incision appear to have an equal risk with and to lack the advan- 
tages which belong to the latter. 

:'s subcutaneous ligature about the fragments (silver or silk 



392 FRACTURES. 

passing through the joint) opens a direct road for the spread to the 
joint of infection occurring at either puncture or small incision, and as 
it also fails to provide for satisfactory evacuation of the joint and 
adjustment of the periosteal fringe I should reject it. It appears to 
have met with considerable favor and success since its introduction in 
1894 and has been warmly commended by several. 

My personal experience is limited to the subcutaneous mediate silk 
suture through the tendon and the ligamentum patellae (1889-1892, 
about forty cases) and open incision with the same or the fibro-perios- 
teal suture (1892-1907, over two hundred cases). In the first series 
infection occurred twice and resulted in a stiff joint, suppuration ap- 
pearing in one of them after the patient had left the hospital, appar- 
ently well, in the second week. In the second series all the cases have 
recovered without accident and with close union, except one case of 
slight superficial suppuration which did no harm ; all that I have seen 
after the third month have had good use of the joint except one very 
stout nervous woman who could not be persuaded to abandon 
crutches ; her patella was freely movable laterally and union was close, 
but flexion was limited to 30 degrees three months after the accident. 

I began with the subcutaneous method because I thought its risks 
less than those of free incision, but when I found that the extrava- 
sated blood often escaped freely through some of the four small incis- 
ions and that consequently the suture lay free within the area of 
fracture and laceration I abandoned it for the single free incision and 
was soon convinced that the patient was equally, perhaps better, pro- 
tected. A special advantage of the latter method is that the operation 
can be done without once touching the cut tissues with the fingers, and 
to that I attribute the complete freedom from infection. I have 
frequently done the operation under local anaesthesia — cocaine or 
freezing. 

The method is as follows : The surface having been prepared, an 
incision is made in the median line slightly overlapping the two frag- 
ments ; the sides are drawn apart, the fragments lifted in turn with a 
sharp retractor, and their surfaces freed from clot or fringe ; while 
they are held up the joint is thoroughly washed with a hot sterile salt 
solution. A stout chromic catgut ligature is passed through the lateral 
expansion and capsule close to the bone on each side ; these are tied 
Avhile the fragments are held in exact apposition, and then the fibro- 
periosteum and other superficial layers adjusted and fastened with cat- 
gut. Blake * trusts entirely to the two lateral sutures. The incision is 
closed without drainage with an uninterrupted silk suture, the dressing 
applied, and the limb bound upon a posterior splint. The patient is 
kept in bed with the foot elevated for a week, the silk suture of the in- 
cision is then removed, and a light plaster-of-Paris encasement applied. 
After a few days the patient leaves the hospital on crutches, and after a 
month the dressing is cut down the middle in front, and he is directed 
to wear it only in the daytime. Usually the joint can be flexed at least 
90 degrees by the end of the third month, often earlier, and the patient 

1 Blake : Journal American Medical Association, Oct. 1, 1904. 



FRACTURES OF THE PATELLA. 393 

usually discards the splint entirely before that time, since he is told it 
serves only as a protection against damage by a fall. In no case have 
I seen the fragments separate under use, but several have come back in 
the third or fourth month with a fiacture caused by a fall. 

I have thrice used a transverse incision ; it permits more exact suturing 
of the rents in the lateral expansions, but I prefer the median incision. 

I have treated a few cases without immobilization after the tenth 
day, but the gain in rapidity of restoration of function has not been 
sufficient to justify the risk of accident. 

For Ceci's l method, first subcutaneous wire suture through bone ; 
Aiken's 2 modification, the wire passing only once through the bone and 
then back under the skin ; Barker's 3 method, subcutaneous ligature 
through the joint about the patella ; my earlier method, 4 subcutaneous 
mediate suture through the tendon and ligamentum, the reader is re- 
ferred to the original accounts. Other plans not above mentioned are 
those of Wolff, 5 open incision, two metal rivets driven into each frag- 
ment to receive silver wires by which the fragments are fastened 
together ; Kittredge, 6 two similar rivets placed astride the line of frac- 
ture ; and Axford, 7 temporary wire suture through the bone and back 
outside the skin. Other older temporary measures are Barton's (1834, 
the same as Axford's), Volkmann's silk loops transversely through the 
tendon and ligamentum patellae and tied together over the skin, and 
Kocher's (1880) surrounding wire ligature, passing like Barker's through 
the joint beneath the patella but, unlike his, including the skin in its 
loop. 

Compound fractures specially need protection from infection be- 
cause of the importance of the joint and the danger to life or limb 
involved in its suppuration. If infection has already occurred the 
joint must be cleaned as thoroughly as possible and drainage provided 
on each side. The fragments must be sutured together. 

Disability After Fracture. This may be due to stiffness of the 
joint or, much less frequently, to the loss of active extension. The 
causes of the former are varied, and but few of those which are per- 
manent, which do not gradually diminish under use, can be removed 
by operation. Many attempts to relieve have been made upon the 
theory that the fault lay in separation of the fragments or in the 
absence of a firm bond between them, the usual plan being to open 
the joint and bring the fragments together. Failures have been numer- 
ous, either through inability to close the gap, or through infection, or 
through persistence of the disability after an operative success. Even 
in many of the cases in which improvement has followed the operation 
it seems probable that an equal improvement would have come in time 
without the aid of the interference. Chaput, 8 who has thoroughly 

1 Ceci: Deutsche Zeitschrift fur Chirurgie, February, 1888. 

2 Aiken : British Medical Journal, July 23, 1892. 

3 Barker: Lancet, April 18, 189(5, and American Text-hook of Surgery, 1897. 

4 Stimson : New York Medical Journal, May 10, 1890. p. 531, and American Text- 
book of Surgery, 1S92. 

5 Wolff: Deutsche med. Wochenschrift, May 14, 1891. 

6 Kittredge: Boston Medical and Surgical .Journal, November 19, 1891, 

7 Axford: Annales of Surgery, July, L898. 

8 Chaput : Fractures anciennes de la Rotule. These de Paris, L885, and La Semaine 
Medicale, June 17, 1891. 



394 FRACTURES. 

studied the conditions, attributes the loss of flexion to hypertrophy or 
rigid elongation of the united patella by which it is made too long to 
pass around the condyles, or, much more frequently, to the ascent of 
the upper fragment (with a separation of two to five centimetres), in 
consequence of which the upper portion of the capsule and the lateral 
expansions become so shortened that the descent of the fragment is 
impossible, and it cannot be sufficiently mobilized without a division 
of its attachments too extensive to be practicable or perhaps compatible 
with its vitality ; and even if the lower fragment is brought up to the 
upper one by detachment of the ligamentum patellae from the tibia 
(Von Bergmann, 1887) and is united with it flexion would still be lost. 
This being so, what is required is not the approximation or reunion of 
the fragments but the removal of the obstacle to the descent of the 
upper one. Chaput did this in one case by excising the upper fragment 
and obtained a good result, the patient being able to walk up and down 
stairs and carry a burden of 200 pounds ; the range of motion is not 
stated. His grouping of the different forms and their respective treat- 
ment is as follows : 

1. Close union. Medical treatment and exercise. 

2. Elongation of the patella by hypertrophy or a stiff bond with loss 
of flexion. Extirpation of the patella. 

3. Short flexible bond. Massage. 

4. Bond two to five centimetres long with loss of flexion. Extir- 
pation of upper fragment. 

5. Bonds more than five centimetres long, and those cases of class 
4 in which active extension is lost. Suture of the fragments after free 
separation of the lower portion of the quadriceps and upper part of the 
capsule from the femur. This denudation of the femur he proposes to 
effect through a curved transverse incision at the level of the lower 
fragment or, if the gap is long, through a longitudinal one ; for the 
denudation he would use the elevator or knife and would suture the 
fragments with wire because the strain might be too great for periosteal 
sutures. 

Rupture of Bond (" Refracture "). This has rarely seemed to me to 
require more than rest in bed with the foot elevated. As it is 
caused by the tearing aw T ay of the lower fragment from the upper one 
in forcible flexion, full extension of the joint brings the torn surfaces 
into contact, and we have only to wait for them to reunite, opposing 
swelling, if necessary, by appropriate measures. Once or twice I have 
reopened the joint and again sutured the fragments, and, of course, 
this would be done if the fracture is compound. The prognosis is 
made worse by the prolongation of the confinement and the repetition 
of the trauma and its consequences. 

Schanz l obtained a good functional result in a fracture five years 
old with a separation of twelve centimetres. Through an incision on the 
inner side from below the knee to the middle of the thigh, over the 
sartorius, this muscle w r as mobilized and secured by wire sutures upon 
the front of the fragments. Six weeks after operation the patient 
could run up stairs. 

1 Schanz: Beilage zuin Centralblatt fur Chir., 1903, p. 157. 



PLATE XXXIX 




Fracture of Upper End of Tibia by Abduction of the Leg. 



CHAPTER XXV. 

ERACTURES OF THE BONES OF THE LEG. 

Of the upper end of tibia or both, separation of epiphysis of the tibia, avulsion 
of the spine, avulsion of the tubercle — Of the shaft of the tibia or both — 
At the lower end: Comminuted, supramalleolar, separation of epiphysis of 
tibia, by eversion and abduction (Potts), by inversion, of the posterior portion 
of the tibia — Of the fibula: Upper end, shaft, separation of epiphysis. 

Accokding to the table in Chapter I. fractures of the shaft of the 
tibia or of both bones constitute one-fourth of those of the lower ex- 
tremity, and more than 6 per cent, of all fractures. The more fre- 
quent seat is at or near the junction of the lower and middle thirds. 
When both bones are broken the fibula is usually broken at a higher 
level than the tibia. 

Statistics show that infancy and childhood are almost exempt, and 
that the maximum of frequency is found between the ages of thirty 
and sixty years, those three decades, according to Malgaigne, furnish- 
ing equal numbers. 

1. FRACTURES OF THE UPPER END OF THE TIBIA AND FIBULA 
OR OF THE TIBIA ALONE. 1 

The causes of these fractures are direct and indirect violence ; in the 
former a blow received directly upon the part, as the fall of a heavy 
body or the kick of a horse ; in the latter a fall from a height or a 
twist of the limb, especially abduction. 

The line of fracture may be transverse, oblique, or longitudinal, in 
the latter case passing into the joint and separating only a portion of 
the articular end from the shaft, or there may be a crush of the internal 
condyle of the tibia with rupture of the external lateral ligament. 
Transverse fractures by direct violence, the fall of a stone, the kick of 
a horse, have been observed at four and seven centimetres from the 
articular edge. Comminuted fractures have been caused by direct 
violence and by falls upon the feet, the shaft penetrating and splitting 
the head. Oblique fracture, the line running into the joint and sepa- 
rating the whole or part of either condyle, appears to be caused by 
abduction or adduction of the leg, the fracture taking place on the side 
toward which the leg is bent. The term compression fracture (Wag- 
ner) has been applied to a group comprising fracture of either condyle 
and more or less marked crushing of the head of the tibia by a tall 
upon the foot. Excluding the fractures of either condyle, in the pro- 
duction of which abduction and adduction of the leg take part respec- 

1 Including separation of tin 1 upper tibial epiphysis and avulsion of the tubercle of the 
tibia. 



396 



FRACTURES. 



tively, thev are characterized by swelling in and below the knee and 
by sensitiveness on pressure. 

Of longitudinal fracture I have seen one case, a man of twenty-five 
years. The line of fracture ran from the inner part of the outer artic- 
ular surface directly downward in a sagittal plane. The separation at 
the upper end was about half an inch and was maintained partly by a 
small fragment lodged deeply in the cleft, but even after removal of 
the latter the displacement could not be wholly reduced. The cause 
was a fall from a ladder, but the mechanism was not known. The 
joint was so loosened that the tibia could be moved outward nearly half 
an inch. Recovery took place with active flexion nearly to a right 
angle and marked genu valgum. 

The displacement varies with the character of the fracture and the 
fracturing force ; in a transverse fracture without comminution it is 
usually slight ; in comminution of the upper end and in oblique frac- 



Fig. 234. 



Fig. 235. 



Fig. 236. 




Fracture of the head of the tibia with 
impaction and separation of the upper 
fragments. 




Fracture of the head 
of the tibia. 



Fracture of upper ends 
of both bones. 



ture of either tuberosity the fragment may be 
...,_ notably displaced or tilted. The direct or indirect 

/wSi i^^f'f 1 implication of the joint ensures an effusion within 
IJlpi^" ) || it, and the proximity of the main vessels makes 
||§|||| their injury more likely than in fracture at most 
other points. Both tibial arteries and the pop- 
liteal vein have been torn, the injury in every case 
leading to amputation or death. 
Diagnosis. The diagnosis, in reaching which the aid of an anaesthetic 
may be required, is made by recognition of the irregularity of outline, 
pain on local pressure and on pressing the leg upward, and possibly 
abnormal mobility and crepitus. In high transverse fractures care 
must be taken not to mistake the injury for a subluxation of the knee. 
Prognosis. The prognosis of this injury is exceptionally serious, 
because of the proximity of the joint and the possibility of inflamma- 



FRACTURES OF THE RONES OF THE LEO. 397 

tory complications and the more or less complete loss of the functions 
of the knee which that and the derangement of the articular surface in 
oblique and comminuted fractures involve, and also because of the 
exceptionally long period that is necessary for consolidation. The 
average period in seven cases collected by Poncet was about four 
months. No satisfactory explanation has been given of this peculi- 
arity. 

Treatment. Displacement must be corrected by traction and direct 
pressure according to its character, and retention effected either by 
permanent traction or by a suspended posterior splint with the knee 
partly flexed or by encasement of the entire limb in plaster. The 
indications vary so much with the position, direction, and extent of 
the fracture that general rules cannot well be made. Complete encase- 
ment is valuable to prevent bowing of the knee when the fracture 
extends into the joint. 

When the fracture extends into the joint function may be so limited 
by an irregular position of the articular fragments that it may be wise 
to expose them by incision for more accurate adjustment. With proper 
precautions it would be justifiable if the irregularity is great and not 
otherwise remediable, but I have met with only one case that seemed to 
require it. 

If the fracture is compound and if suppuration of the joint occurs 
a free outlet for the pus must be promptly provided by special open- 
ings at the sides rather than through the wound which can hardly fail 
to be unsuitably placed for effective drainage. 

Separation of the Epiphysis 

has been noted in a few cases. Bruns collected four, Hutchinson 1 says 
he has records of ten, including three unpublished cases, and Poland 2 
collected twenty-four. The recently reported cases that I have seen 
are those of Heuston and Manly. 3 In Hutchinson's list the extremes 
of age were one and sixteen years. The common cause appears to be 
a wrench of the leg, abduction or adduction, by which a transverse 
strain is made, but Poland thinks it is direct pressure against the epiph- 
ysis. One of Poland's was compound ; the patient recovered. In 
twelve the patient died or the limb was amputated. The ages ranged 
from three to twenty years. In all but. one case the process bearing the 
tubercle of the tibia accompanied the epiphysis. The displacement was 
forward, forward and outward, or lateral, and usually slight. In a num- 
ber the diaphysis was also broken, and sometimes extensively. In 
several of the cases which recovered no trace remained of the injury. 

Avulsion of the Spine of the Tibia 

Previous to the introduction of the .r-rays this injury was known 
only as a complication of dislocation of the knee, produced by traction 

1 Hutchinson: British Medical Journal, March 81, 1894. 

2 Poland: Traumatic Separation of the Epiphysis, p. 802. 

3 Heuston and Manly: British Medical Journal, July 21 and September 22, 1SSS. 



398 FRACTURES. 

through the crucial ligament. Recently several cases have been recog- 
nized by the aid of the arrays in much slighter injuries of the joint, so- 
called sprains or twists. Lange 1 published two such. Apparently the 
diagnosis can be made only in this way. The displacement is slight, 
and the only available treatment is immobilization, preferably I should 
think, in full extension. 

Avulsion of the Tubercle of the Tibia. 

To the tubercle is attached the ligamentum patellae, and all but one 
of the cases of fracture which have been reported have been caused bv 
the action of the quadriceps in some. violent effort, usually jumping, 
and most of them in youths between twelve and eighteen years of age. 
Overlook 2 reported a case in which the fracture was caused by direct 
violence, the kick of a horse. The frequency in youth is to be ac- 
counted for by the fact that the tuberosity is a downward prolongation 
of the epiphysis and remains separated from the shaft by conjugal 
cartilage until growth is completed. Miiller 3 who wrote the first special 
article upon the subject, collected seven cases and added one of his own. 
Other formal papers are by Schlatter, 4 Osgood, 5 Keyser, 6 Landsberg, 7 
Ware, 8 Gaudier and Bouret, 9 and Linkenheld, 10 who collected twenty- 
seven cases. The size of the fragment has varied in length from two 
to five centimeters, being smaller in the young than in adults, and in 
one exceptional case (Richet) the rupture ran partly through the tubercles 
(both legs) and partly through the ligamentum patellae. The fragment 
is sometimes displaced upward and sometimes rotated forward on its 
upper edge. 

Symptoms. The symptoms are inability to use the limb immediately 
following the effort, which sometimes is accompanied by a cracking 
sound, and the recognition of a movable lump of bone about two inches 
below the patella. On pressing this lump downward and backward 
against the tibia crepitus is felt. The knee-joint is more or less dis- 
tended by an effusion. 

It seems to me that skiagraphic appearances — the existence of a 
clear line between the tubercle and the shaft — have led of late to the 
diagnosis of fracture in some of the common cases of slight injury 
which do not deserve to be thus classed. Thus, Schlatter, who claims 
seven cases in less than three years, includes those in which there was 
no sudden onset, no disability, no symptom except tenderness on press- 
ure, cases, it seems to me, of slight ruptures of the periosteum or 
conjugal cartilage or even of exaggerated nutritive activity. I have 

1 Lange : Annals of Surgery, 1908, vol. 48, p. 117. 

2 Overlook: Conn. State Med. Soc., 1907, p. 288. 

3 Miiller: Beitrage zur klin. Chir., November, 1887, p. 257. 
* Schlatter: Ibid., 1903, vol. xxxviii. p. 874. 

5 Osgood Boston Medical and Surgical Journal, 1903, vol. cxlviii. p. 114. 

6 Keyser : Reported in Sajous's Annual, 1888, vol. ii. p. 267. 

7 Landsberg: Centralblatt fiir Chir., September, 28, 1889. 

8 Ware : Annals of Surgery, November, 1904, p. 739. 

9 Gaudier and Bouret : Revue de Chir., vol. 32, p. 305. 

10 Linkenheld: Deutsche Zeitschrfift ur Chir., vol. 87, p. 226. 



FRACTURES OF THE BONES OF THE LEG. 



399 



seen a lump slowly form at the site of the tubercle in such cases. (See 
also Winslow, Annals of Surgery, February, 1905, and Alsberg, Zeitech- 
criftfur Orthop. Chir., vol. 20.) 

Treatment. The treatment is to press the fragment into place and 
maintain it there by a bandage or strips of adhesive plaster while the 
limb is kept extended upon a splint for four or five weeks. In a few 
cases the fragment has been exposed by incision and secured in place 
with periosteal sutures or even by temporary nailing. 

The ultimate result has been good in all the cases, but in one the 
restoration of motion was not complete until after a year. 



Fig. 237. 



M 



2. FRACTURES OF THE SHAFT. 

Fractures by direct violence may occur at any point ; those by indi- 
rect violence are much more frequent at or near the junction of the 
lower and middle thirds than at any other point. It seems probable, 
as taught more especially by Gosselin, that torsion of the limb is an 
important factor in the production of the fracture, the 
twist being due either to the forcible contraction of the 
muscles or to the propulsion of the upper portion while 
the lower one is fixed by the pressure of the foot upon 
the ground. 

The varieties of fracture common to other long bones 
are found here, and in addition a form of spiral, the 
V-shaped fracture, first pointed out by Gosselin, which 
although occasionally found elsewhere is much more fre- 
quent in the leg. In these, which are especially frequent 
below the middle of the bone, the upper fragment termi- 
nates in front and on the inner side in a more or less 
sharp triangular point, the lower fragment presents a 
similar point posteriorly, and from the bottom of the de- 
pression in the lower fragment which corresponds to the 
first point, sometimes splitting off a superficial fragment 
on the posterior aspect as shown in Fig. 237. The ex- 
tent of the fissures and the implication of the ankle-joint 
give this variety of fracture an especial importance. 

It is uncommon for the tibia alone to be broken when 
the fracture is by indirect violence, for the force con- 
tinues to act, if only for a moment, and breaks the weaker 
fibula all the more easily, and usually at a higher point V-shaped fracture. 
than the tibia. 

The subcutaneous position of the tibia throughout its entire length 
greatly exposes its fractures to the chance of becoming compound either 
by the direct action of the causative violence when the fracture is direct. 
or by the perforation of the skin by the end of one o{ the fragments, 
usually the upper one, when the fracture is indirect. 

The displacements show the usual varieties, but the most common and 
important is the projection of the lower end of the upper fragment 
when it terminates in an anterior point, as it usually does, the eon- 



400 FRACTURES. 

traction of the predominant muscles of the calf aiding it by creating 
an anterior angular displacement. 

In addition to the usual symptoms of crepitus, abnormal mobility, 
pain, and loss of function, there is also the irregularity in the outline 
of the subcutaneous portion of the tibia which may be recognized by 
passing the finger along it. It is not always possible to say whether or 
not the fibula is broken as well as the tibia without making a more 
severe and painful examination than the need of the information will 
justify. When both bones are broken the mobility is usually much 
greater than when the tibia alone is broken, and by making gentle 
pressure with the finger along the line of the fibula the point of frac- 
ture can usually be determined. 

Beside the frequent complication of a communicating wound of 
the skin, and the comminution which is so often the result of direct 
violence, injury to the principal vessels is occasionally met with. 
Nepveu, 1 in a very complete and elaborate paper read before the 
Surgical Society of Paris, collected more than fifty cases*, among which 
are found examples of injury to both tibials, the peroneal, and the 
nutrient artery of the tibia. Injury to the tibial or peroneal nerves 
seems to be much more rare. Mourret collected twenty-seven cases 
of aneurism complicating fracture, five of which were mistaken for 
abscess and opened. 

I have seen hemorrhage occur from the anterior tibial on the eighth 
day after fracture by direct violence without displacement ; the rupture 
was one and a quarter inches above the fracture and was evidently due 
to bruising of the artery by the wheel which caused the fracture. 

A simple fracture without persistent displacement will usually become 
firmlv consolidated in six weeks ; but in the comminuted ones and in 
those that are oblique with persistent displacement the callus remains 
weak much longer. Complete recovery is long delayed by rigidity at 
the ankle, tenderness of the skin, feebleness of the circulation, and 
neuralgic pains which are more common after fractures of the leg than 
after those of other long bones. In the old and rheumatic this delay 
is especially prolonged. 

If the suppuration becomes free after a compound fracture it is prob- 
able that complete recovery will be postponed for even a much longer 
time, and that sinuses leading down to bare or necrosed bone will re- 
main open for many months or will reopen at intervals. On the other 
hand, the subcutaneous position of the tibia makes it easier to drain the 
cavity of the fracture thoroughly and to remove splinters, and thus 
makes the danger to life less than after compound fracture of bones that 
are more deeply placed. 

Treatment. Reduction of the displacement can generally be made 
by traction at the foot and counter-extension at the knee, this joint 
being slightly flexed to relax the muscles of the calf. In the more 
difficult cases in which spasm of the muscles opposes reduction com- 
pression of the femoral artery for a few minutes, as suggested by Broca, 
has sometimes seemed to be useful in my experience. In a small pro- 
portion of cases complete reduction is impossible, probably because of 

Nepveu : Bulletins de la Societe de Chirurgie, 1875. p. 365, 



FRACTURES OF THE BONES OF THE LEG. 



401 



the interposition of a small pieee of bone or of a muscular bundle 
between the fragments. 

Maintenance of the reduction depends largely upon the character of 
the fracture ; when this is nearly transverse and toothed, the displace- 
ment is unlikely to recur ; but when it is oblique the difficulties of 
complete retention may be great. The segment of the limb below the 
fracture is too short to permit traction by strips of adhesive plaster, as 
in fracture of the thigh, and the surgeon has to depend upon some form 
of splint or an immovable dressing, neither of which will certainly 
prevent shortening, although the amount may be so slight as to be 
without practical importance. 



Fig. 238. 



Fig. 239. 





Bivalve or stocking splint. 



Posterior gypsum splint or gutter. 



The usual routine of treatment in simple fractures without marked 
displacement is to put the patient in bed with the limb in a Volkmann 
splint (Fig. 35) for about a week or until the swelling has subsided, 
and then to encase it in plaster of Paris. Under the prolonged use 
of the Volkmann splint some shortening, usually slight, is likely to 
occur. Immediate application of plaster is objectionable because either 
the swelling is likely to increase and make the dressing too tight, or it 
will diminish and leave it too loose. The stocking bivalve plaster 
splint (Fig. 238) is a convenient means of combining the advantages 
of the primary Volkmann splint and the later encasement. The 
details of its construction are given on page 94. Care must be taken 



to maintain full length of 



lejr and to avoid anarular or rotators- 



displacement during the hardening of the plaster. Two angular dis- 
placements are specially liable to occur : a Lateral one, apex inward, by 
erroneous correction of the apparent normal curvature in the opposite 

26 



402 



FRACTURES. 



direction ; and an anteroposterior one, by dropping or elevation of the 
heel respectively. The plaster stocking can be applied while the injury 
is recent, and loosened or tightened as the need arises, and it permits 
easy inspection to detect and correct such displacements as may occur 
beneath it. It also permits massage and the application and change of 
such dressings as may be needed for associated wounds of the skin or 
for blisters. 

It may become so loose after a week or two that it does not properly 
support the fragments, and should then be renewed. It should be 
worn until mobility can no longer be recognized, usually five to seven 
weeks, and the patient can go about on crutches during most of that 
time. If union is delayed beyond that time it is well to let the patient 
bear part of his weight upon the foot in walking, angular displacement 
thereby being prevented by a strong plaster encasement. 

Instead of a Volkmann splint during the first week side splints of 
wood or wire or a posterior plaster moulded splint (Fig. 239) or pos- 
terior and lateral splints (Figs. 251 and 252) may be used, and they 
may also, especially the moulded ones, be serviceable during the later 
stages if wounds of the anterior soft parts require dressing. 

A number of devices for maintaining continuous traction have been 
suggested, but their inherent defects are such that they have never come 
into general use. Figs. 240 and 241 show two such. 

Fig. 240. 




Dr. Xeill's dressing for continuous traction. 

Direct pressure by a metal pin or a pad controlled by a screw was 
occasionally used when the projecting end of the upper fragment could 
not otherwise be controlled and especially if it threatened to perforate 
the skin. It is now generally deemed better to expose the fracture by 
incision and remove the cause. 

In compound fractures the bivalve or fenestrated or interrupted splint 
may be used, or anterior and posterior moulded splints one of which 
holds the fragments in place while the other is removed that the dress- 

Fig. 241. 




Continuous traction in fracture of the leg. 



ing may be changed. The details of treatment of the wound are here 
of special importance, and particularly the distinction to be made 



FRACTURES OF THE BONES OF THE LEG. 403 

between fractures that are compound by direct violence and those by 
indirect violence. For these and for ambulatory treatment the reader 
is referred to Chapter VII. 

Suspension may be employed with anv of these splints and often 
promotes comfort notably. 

3. FRACTURES AT THE LOWER END OF THE LEG. 

In this group I place the rare fractures of both bones in which the 
lower end of the tibia is crushed or splintered, separation of the lower 
epiphysis of the tibia and the allied supramalleolar fracture, the numer- 
ous and varied fractures of one or both bones at or near the joint caused 
by forcible inversion or eversion of the foot, sometimes aided by the 
weight of the body, of which the most common is known as Pott's 
fracture, and the much rarer fractures of the anterior and posterior 
articular portions of the tibia. The feature which almost all have in 
common is the action of the causative violence through the foot. 



Fig. 242. 



A. Comminuted Fracture of the Lower End of the Tibia with Frac- 
ture of the Fibula. 

The fractures which constitute this group are too rare and varied to 
permit a systematic description. The tibia is broken either by direct 
violence acting upon its side to crush it, or, more frequently appar- 
ently, by a fall from a height in which the bone 
is broken by a transverse strain and then its 
lower portion split by the penetration into it of 
the other. Thus, in a case reported by Chassaig- 
nac the , tibia was broken four finger-breadths 
above the joint and the lower fragment split into 
four pieces ; the fibula was broken at two places 
in its lower third. A specimen in the museum 
at Val de Grace is shown in Fig. 242 ; the lower 
end of the tibia was broken into fragments. 

Diagnosis. The diagnosis must be made by 
recognition of the abnormal mobility and the 
mobility of the fragments ; probably the aid of 
anaesthesia would always be necessary to apprecia- 
tion of the details. 

Treatment. The treatment must aim to effect 
and maintain as complete reduction as possible, 
acting upon the fragments by traction through 
the foot and by direct pressure. The implication 
of the joint and the frequent derangement of the 
articular surface by fragmentation make loss of 
function in the ankle-joint inevitable, and therefore the foot must be 
maintained at right angles to the leg and without eversion or inversion 
of the sole in order that its usefulness may not be further diminished 
by a fixed faulty position. If the injury is compound by direct 
violence amputation may be expected to give a better functional result 
than conservative treatment in most eases. 




Comminuted fracture 
of the lower portion of the 

leg. 



404 



FRACTURES. 



B. Supramalleolar Fracture. 

This term was created by Malgaigne and applied to fractures which 
for the most part were low or partial forms of the preceding class, 
the line of fracture always running into the joint and usually com- 
minuting the end of the bone, but there are cases in which the 
tibia is broken across within an inch or two of its lower surface 
and with fracture of the fibula at or above the same level. I have 
seen one in which the tibia was broken squarely across, one inch 
above its lower end, the fibula was broken at the junction of the 
upper and middle thirds, and the tip of the external malleolus 
was broken off. Tillaux x was able to produce this form experi- 
mentally by inversion of the foot, and says the fracture then takes 
place first in the fibula, and only in the tibia if the force con- 
tinues to act ; he reports one case in which dislocation of the upper 
end of the fibula took the place of fracture of that bone, the line of 
fracture of the tibia lying three finger-breadths above its lower sur- 
face. In the few cases I have seen the mechanism could not be 
learned, but I see no reason to doubt that it can be effected also by 
eversion of the foot; in the case above quoted the lower fragment 
could be easily displaced outward, but not inward. 

Fig. 243. 




Supramalleolar fracture. 



Diagnosis. The diagnosis is made by pain on pressure along the 
line of fracture and on pressing the foot up against the leg, and pos- 
sibly by recognition of abnormal mobility and crepitus. 

1 Tillaux : Anatoiuie topograph ique, p. 1174. 



FRACTURES OF THE BONKS OF THE LEG. 



405 



Treatment. The 
dressing, using the 



treatment is immobilization, preferably in a fixed 
foot to control the position of the lower fragment. 



C. Separation of the Epiphysis of the Tibia. 

This is more frequent than that of the upper epiphysis, 11 to 4 in 
Bruns's 100 cases of all kinds. The cause appears to be a cross-strain 
in eversion and perhaps in inversion of the foot, sometimes the result 
of great violence, as in a fall from a height, sometimes a simple twist- 
ing of the foot in a misstep. Experiments indicate that it may be pro- 
duced by forcible dorsal flexion of the foot combined with pressure 
against the sole. 

In some cases, as in Fig. 244, the outer portion of the shaft is broken 



injury is compound 



Fig. 244. 




off, evidently during eversion ; and in some the 
with marked protrusion of the shaft through 
the wound on the inner side. The fibula is 
almost always broken at a higher point, and 
although the upper limit of its own epiphysis 
is situated well below that of the tibia its sepa- 
ration occasionally takes the place of fracture 
of the shaft. 

Hutchinson collected eight reported cases of 
arrest of growth after the injury, with over- 
growth of the fibula and inversion of the foot. 

The principle of treatment is the same as in 
supramalleolar fracture. 



D. Fractures by Eversion and Abduction of the 
Foot. Pott's Fracture. 

Beside being a very common injury this gains ep «° »/ £ ££ 
special importance from the frequency with (bruns.) 
which the cardinal principles of its treatment 

are overlooked and the occasional great disability which results. The 
lesions vary much in extent and detail ; indeed, occasionally fracture 
is wholly absent and some of the forms have been classed with dislo- 
cations. But these differences are due either to alternative lesions or 
to the early cessation of the force before the typical form has been 
reached, and the mode of production in its two forms is constant, so 
that all the variations are parts of a single nosological entity. The 
differences make a name anatomically descriptive of the group almost 
impossible; the one above given, based on the mode of production, is 
useful to distinguish the group from the following one which has cer- 
tain points of resemblance, and correctly includes all the forms, but it 
is not suitable for current use ; the alternative title. Pott's fracture, 
has not only the advantage of convenience but also that of long asso- 
ciation with the injury. It deserves, I think, to be retained as the 
principal name. 

Cause and Pathology. The cause is a twist of the toot — eversion 
and abduction — aided somewhat by the weight of the body. Accord- 



406 FRACTURES. 

ing as the eversion or the abduction predominates the lesions take one 
or the other of two easily distinguishable forms, as follows : 

If eversion is the sole, or main, movement the force is exerted 
through the internal lateral ligament and breaks the internal malleolus 
squarely off at its base ; then it presses the external malleolus out- 
ward, rupturing the tibiofibular ligament, and breaks the fibula close 
above the malleolus. Sometimes, instead of pure rupture of the tibio- 
fibular ligament, there is avulsion of the portion of the tibia to which 
it is attached, in front or behind or both, but I believe this to be rare. 
These lesions can be easily produced experimentally by fixing the foot 
in a vise and pressing the upper part of the leg outward. 

If, on the other hand, abduction of the front of the foot is the 
principal movement the first and last of these three lesions vary : 
instead of a square break of the internal malleolus at its base, there 
is an oblique, almost marginal, fracture of its anterior portion, or, 
more commonly, there is rupture of the anterior portion of the internal 
lateral ligament; then follows rupture of the tibio-fibular ligament, 
and, as the movement continues, the torsion of the fibula produces an 
oblique fracture the upper end of which is found three or four inches 
above the tip of the malleolus. If the movement is arrested in time 
fracture of the fibula may not occur. Experimentally this can be easily 
produced and the sequence of events accurately observed. Clinically 
it cannot be demonstrated so easily, for the patient can rarely give a 

Fig. 245. 




Pott's fracture, right side ; showing outward displacement and absence of eversion. 

detailed account of the manner in which the injury was received, but 
in one of my cases the mechanism was evident : while the patient was 



PLATE XL 




Separation of Lower Tibial Epiphysis 



PLATE XLI 




Fig. 1. 



■Pott's Fracture by Eversion in a Youth ; showing also epiphyseal line 
internal malleolus broken at its base. 




Fig. 2. — Fracture of the Posterior Portion of the Lower End of the Tibia, 

with Fracture of Fibula and Internal Malleolus 



PLATE XLII 




Fig. 1,— -Pott's Fracture by Abduction ; male, forty years 
internal malleolus unbroken. 




Fig. 



-Pott's Fracture, two months old, back-ward displacement 



FRACTURES OF THE BOXES OF THE LEO. 



407 



kneeling on one knee, the foot resting on the hyper-extended toes, lie 
was pressed backward so that his buttocks rested on and forced the 
ankle inward, causing abduction of the front of the foot. The essen- 
tial lesion is the tibio-fibular diastasis, the rupture of those ligaments, 
and the consequent widening of the mortise within which the astrag- 
alus is held. 

Exceptionally the displacement of the foot and fibula may be 
extreme, even without fracture of the fibula. (See Outward Disloca- 
tion of the Foot.) And, also exceptionally, unusual lines of fracture of 
the tibia may be found, such as a long one running up from the artic- 
ular surface and separating a fragment consisting of the outer portion 
of the bone, or a breaking off of the posterior portion of the articular 
surface (see section F) ; in both of these the weight of the body must 
be an important causative factor. 

Two complications which may appear in the first variety were, so 
far as I know, first observed and reported by me ; l I have seen two 

Fig. 246. 




The same ; showing backward displacement. 



cases of each. One is the rotation of the internal malleolus about an 
antero-posterior axis so that its fractured surface lies parallel to ami 
just beneath the skin, the fragment being exceptionally prominent ami 

1 Stimson : Transactions of the New York Surgical Society, in New York Medical Jour- 
nal, January 26, 1889, p. 108, and Pott's Fracture, New York Medical Journal, June J.\ 
1892. 



408 



FRACTURES. 



movable. The other is the interposition between the malleolus and the 
tibia of a large strip of periosteum torn from the tibia ; in this condi- 
tion also the malleolus is exceptionally prominent and movable. In 
all my four cases the fracture was exposed and readjustment made 
through an incision ; recovery followed with full restoration of func- 
tion. 



Fig. 247. 



Fig. 248. 




Pott's fracture ; method of recognizing abnormal lateral mobility. 



A third case of the first form recently (1909) seen is interesting as 
a variant and as showing one form of mechanism clearly. A man 
caught between an elevator and its shaft received an injury at the ankle 
and also a low compound fracture of the thigh with laceration of the 
popliteal vessels which made amputation necessary. The internal malle- 
olus was broken off at its base and so rotated that its fractured surface 
faced the skin. It was held in position by slight interposition of 
the tendon of the tibialis posticus, but could be easily replaced, and as 
easily redislocated by eversion of the sole. The external malleolus and 
the lower tibio-fibular ligaments were uninjured. On exposing the 



FRACTURES OF THE BONKS OF THE LEO. 100 

joint in front and gently routing the sole the astragalus could be seen to 
turn slightly on the external malleolus as a centre and press with its 
upper, inner border the internal malleolus out of place. The fracture 
appeared to have been caused by the pressure of the astragalus, not by 
evulsion through the deltoid ligament. The case differs from the com- 
mon form in the absence of the associated pressure downward which 
must habitually co-exist when the injury occurs while the patient is 
standing. 

Another, not very uncommon, complication of the first variety is 
laceration of the skin on the inner side by the end of the tibia, which 
may project through the wound ; this is due to the prolongation of the 
action after fracture, by which the foot is forced outward and everted 
and the skin torn across the broken edge of the tibia. The displace- 
ment is of the foot (astragalus) and outer malleolus outward and back- 
ward. This displacement is usually slight, a quarter of an inch, but 
it may be much more, and the backward displacement is sometimes so 
great that the body of the astragalus lies almost wholly behind the tibia. 

Symptoms. The appearance of the region is usually so characteristic 
that the diagnosis can be made at a glance, the characteristic feature 
being the outward displacement of the foot and the corresponding prom- 
inence of the internal malleolus or the adjoining portion of the tibia 
(Fig. 245) ; in the marked cases the backward displacement is also 
plainly to be seen (Fig. 246). The former is most apparent when the 
muscles are relaxed, as by anaesthesia, or when swelling is absent. 

The pathognomonic signs are the points of tenderness mentioned 
below and abnormal lateral mobility at the ankle, which can be shown 
by grasping the foot with one hand so that the posterior portion of the 
sole rests in the palm, with the thumb close below the external malle- 
olus, and the index-finger below the internal malielous, and moving it 
bodily inward and outward while the other hand grasps the leg above 
the ankle and steadies it (Figs. 247 and 248). This manipulation some- 
times produces a distinct click by the impact of the astragalus against 
the internal malleolus or of the external malleolus against the tibia. 

In like manner abnormal mobility backward and forward can some- 
times be shown by clasping the back of the heel with the fingers of 
both hands, placing the thumbs on the front of the lower part of the 
tibia, and then alternately lifting the foot and allowing it to drop back, 
the patient being recumbent. 

Three points of tenderness on pressure are constant and character- 
istic : one in front at the position of the tibio-fibular ligament, that is, 
in the groove between the tibia and the external malleolus, showing 
the rupture of this ligament ; one at the base of the internal malleolus 
or near its anterior border or just in front of it, marking the fracture 
of the malleolus or the rupture of the anterior portion of the lateral 
ligament; the third over the outer aspect of the fibula, close above the 
malleolus in the first variety, an inch or so higher in the second, mark- 
ing the fracture of the fibula. Abnormal mobility of the two t'rag- 
ments may sometimes W recognizable. 



410 



FRACTURES. 



Marked ecchymosis appears beneath the external malleolus and 
usually also beneath the internal. 

Pressure upward against the heel is not painful, and the patient can 
sometimes walk if he steps carefully and without much movement in 
the ankle-joint. 

Prognosis. If reduction is made and maintained the prognosis is 



Fig. 249. 



Fig. 250. 




Old Pott's fracture ; outward 
displacement. 



The same ; backward displacement. 



good, the patient almost always gaining full use of the joint, but if 
either backward or outward displacement persists (Figs. 249 and 250) 
the disability is likely to be marked. Backward displacement limits 
dorsal flexion at the ankle, and the patient is, therefore, obliged to turn 
the toes well outward in walking; outward displacement brings the 
weight of the body too far to the inner side of the foot and thus pro- 
duces a strain upon the internal lateral ligament which promptly causes 
fatigue and pain. 



FRACTURES OF THE BONES OF THE LEO. 



411 



Treatment. Reduction, to facilitate which anaesthesia is sometimes 
advisable, is made by pressing the calcaneum forward and inward; the 
hand is placed against the back and outer side of the heel and pressed 
forward and then forcibly inward. It is best maintained by a poste- 
rior and a lateral plaster splint, such as those shown in Figs. 251 and 
252. They are preferable to complete encasement in plaster because 
they permit inspection of the inner side of the ankle and the immediate 



Fig. 251. 




Pott's fracture ; posterior plaster splint. 

detection of recurrence, and to wooden splints (Fig. 25.3) because they 
are more secure. They can be conveniently made of a four-inch plaster 
roller by soaking it and running it back and forth on a table until 
twelve or fifteen layers of suitable length have been put together. The 
posterior splint should extend from the toes, along the sole, and up the 
calf nearly to the knee. The lateral one should begin just in front of 
the external malleolus, pass over the dorsum of the foot to the inner 
side, under the sole, and up along the outer side of the leg to the same 
height. They are snugly moulded and bound to the limb while still 
wet with a roller-bandage which may be removed after the plaster 
has set, its place being taken by a few turns of a bandage just above 



Fig. 252. 




Pott's fracture; lateral plaster splint. 



the ankle and at the upper end of the splint. While the plaster is 
settiiiir reduction must be maintained by an assistant or bv resting the 



412 



FRACTURES. 



heel on a sand-bag with the limb in outward rotation so that the foot 
will be pressed forward and inward. I have sometimes placed the 
lateral splint on the inner side. 



Fig. 253. 




Dupuytren's splint. 



Fig. 2)4. 



Fig. 255. 




Pott's fracture ; same case as in Figs. 249 and 250 ; showing result of operation. 

Such a splint may be conveniently and safely applied immediately 
after the accident, for if strangulation should threaten the circular 
bandages can be lossened sufficiently to relieve the constriction without 
disturbing the position of the foot. If applied while the limb is swol- 



FRACTURES Oh THE BONES OF THE LEO. 413 

leu the shrinking ean be met by tightening the circular bands, but it 
is better to apply a new one after a few days. 

In compound fracture with a small wound infection can generally be 
avoided by the usual measures, and a good result obtained. If the 
wound is or should become infected drainage must be made: on both 
sides, and the foot kept square upon the leg that its usefulness may be 
as great as possible after the probable result of anchylosis. 

In the rare cases of rotation of the internal malleolus or interposition 
of a strip of periosteum the condition should be corrected through an 
open incision. 

In old fractures with unreduced displacement relief can be had only by 
operation. Supramalleolar osteotomy enables the foot to be brought 
back into line with the leg, but does not correct the backward displace- 
ment which almost always coexists. I have never employed it, but 
have always resorted to a formal attempt to bring the astragalus and 
external malleolus back to their places, using two lateral incisions, as 
follows (Figs. 254, 255) : 

One incision begins at the front of the fibula three inches above the 
ankle, is carried downward, passing in front of the malleolus, and then 
curved forward on the side of the foot ; the fracture is exposed and the 
lower fragment again detached. The second incision begins on the 
inner side of the tibia at the same level as the first and passes down to 
the front of the malleolus and thenceforward to or beyond the tubercle 
of the scaphoid. Through it the internal malleolus, if it was broken 
off in the original injury, is again detached from the tibia with a chisel, 
and the end of the tibia protruded so that it is easy to liberate the 
astragalus and cut away any new growth of bone that may have formed 
on the back of the tibia. The foot is then easily restored to place, the 
incisions closed, and a bulky dressing applied and covered with plaster 
of Paris. In the nine or ten cases in which I have done this the res- 
toration of form has been complete, and that of function always 
an improvement upon the previous condition and sometimes a very 
marked one. 

E. Fractures of the Malleoli by Inversion of the Foot. 

This injury, which also is a common one, presents several varieties 
differing notably in the extent of the lesions, the immediate disability. 
and the prognosis. The fibula may be alone broken at or close above 
the base of the malleolus or at the epiphyseal line in the young, or 
with its fracture may be associated that of the tip of the internal mal- 
leolus or one passing obliquely upward and inward through the tibia and 
separating a fragment composed of the internal malleolus and a consid- 
erable portion of the adjoining bone (XLIIL, and XLVL). The 
variations appear to be due to differences in the amount or Force ot' 
the inversion and to the extent to which the weight of the body acts 
as a, factor. Thus, the first effect oi' inversion is to break the fibula, 
either by the pressure of the upper edge of the astragalus against it or 
by the pull of the external lateral ligament ; if the movement is cow- 



414 FE AC TUBES. 

tinued, or possibly of its direction is somewhat different, the astragalus 
presses against and breaks off the tip of the internal malleolus ; but if 
the weight of the body is added, as in a fall upon the inverted foot, the 
astragalus presses upward and inward against the inner portion of the 
tibia and breaks off the larger fragment. 

The first form of the injury, fracture of the external malleolus or 
fibula alone, is of slight importance if the tibio-fibular ligament is not 
also torn, producing no displacement of the astragalus and getting well 
under a simple protective dressing. The same is nearly equally true 
of the second form, added fracture of the tip of the internal malleolus, 
but more time is required before the limb can be freely used. The 
third form is much more serious and usually results in considerable 
restriction of motion at the joint. 

If the tibio-fibular ligament is freely torn the first two forms are 
almost identical with the form described in the preceding section ; 
there are the same points of tenderness on the outer side and the same 
lateral mobility in the joints. 

Diagnosis. The diagnosis is made in the first two varieties by recog- 
nition of tenderness on pressure at the lines of fracture and of inde- 
pendent mobility of the external malleolus by pressing its tip inward 
while another finger is placed at the seat of fracture to feel the tilting 
of the upper end of the fragment. In the third variety the line of 
fracture of the tibia can be recognized by tenderness on pressure and 
by the irregularity produced by the displacement upward and inward 
of the fragment. 

Treatment. For the first two varieties it is sufficient to immobilize 
the part by plaster of Paris, taking care to keep the foot well pressed 
inward while the plaster is setting in order that the malleolar mortise 
shall not be widened. In the third variety the effort must be made to 
correct the displacement of the tibial fragment by pressing it down- 
ward and outward, and to immobilize with the foot well forward, 
guarding against backward displacement, and the external malleolus 
pressed snugly against the tibia, guarding against outward displacement. 

F. Fracture of the Posterior Portion of the Articular Surface of the 

Tibia. 1 

This may be a complication of Pott's fracture, the fragment being 
rather small, or the crush may be so extensive that the symptoms and 
treatment are very different. In the slighter form the breaking of the 
tibia is apparently produced by the weight of the body pressing the 
posterior and outer part of the articular surface against the displaced 
astragalus, and yet I have known it to be caused by the comparatively 
slight violence of a fall from an almost stationary bicycle. I have 
never seen it in a fresh injury and do not know whether it could be 
recognized ; the signs of Pott's fracture would be recognizable, of 
course, and possibly the additional fracture might be shown by dis- 

1 See also Backward Dislocation of the Foot. 



PLATE XLIII 




Fig. 1.— Pott's Fracture by Abduction; same as Plate XLII, Fig. 2. 




Fig. 2.— Bi malleolar Fracture by Inversion: boy fourteen years. 
External malleolus separated at epiphyseal line : fracture of interna. 
malleolus does not show, but was recognized clinically. 



PLATE XLIV 




Fracture by Eversion, with Interposition of the Astragalus. 



PLATE XLV 




Longitudinal Fracture of Lower End of the Tibia bj a Fall upon 

and Inversion of the Foot. 



PLATE XLVI 




a Youth. Line of fracture 



Fig. 1. — Bimalleolar Fracture by Inversion 
passing above the base of the internal malleolus; external malleolus 
separated at epiphyseal line. 




Fig 



2.— Fracture of Femur. Remai n i rig Ununited a Year after w 
Note detachniont of the wire 



FRACTURES OF THE BONES OF THE LEG. 415 

placement of the foot (astragalus) slightly upward as well as backward 
and outward. 

The treatment is that of Pott's fracture with special care to bring the 
foot well forward. 

The more severe form is rare and apparently the result of a fall fr 
a height upon the foot. I have one old specimen of extensive crushin 



om 

(r 



Fig. 256. 




Fracture and displacement of the posterior portion of the lower articular surface of the 
tibia and of the fibula and internal malleolus (See also Plate XLI., fig. 2. ) 

with fracture of the external malleolus and its displacement backward, 
but repair has obliterated most of the details. I have seen another 
in the collection of Dr. Dandridge, of Cincinnati, in which the poste- 
rior half of the tibial plateau is broken off and has united with the 
back of the tibia after displacement of more than half an inch upward. 
The fibular fragment is rather short and is displaced angularly, the 
astragalus having slipped outward between it and the tibia ; the inter- 
nal malleolus is broken off at its base and has accompanied the astrag- 
alus. In two old cases treated by operation (Figs. 256 and 257) I have 
found similiar lesions and displacements. 

Probably under an anaesthetic the general condition, if not the details, 
could be recognized by palpation. The treatment would be to make 
such reduction as was possible and to immobilize in plaster splints. 

In two old cases I have removed the posterior fragment of the tibia. 



416 FRACTURES. 

corrected the displacement, and obtained a useful limb with obliteration 
of the ankle-joint. In a third, I removed the remaining articular sur- 

Fig. 257. 




Same case as Figure 256. 

face of the tibia and flattened the top of the astragalus so that the two 
became firmly united ; the functional result was excellent. 

G. Fracture of the Anterior Portion of the Articular Surface of the 

Tibia. 

Only one or two cases of this variety have been reported. It is 
evidently produced by the pressure of the astragalus against the anterior 
lip of the tibia. Displacement could probably be corrected by traction 
through the anterior portion of the capsule in forced depression of the 
front of the foot aided by direct pressure upon the fragment. 

4. FRACTURES OF THE FIBULA. 

A. Fracture of the Upper End. 1 

This may be caused by direct violence, by muscular action (contrac- 
tion of the biceps), or more commonly by forcible adduction of the leg 

1 For reported cases, which are not numerous, see the first edition of this work 
and Gurlt's Knochenbruche, vol. i. p. 243; Duplay, Bull, de la Soc. de Chirurgie, 
1880, p. 218; Terrier, Idem, p. 222; Leggatt, Lancet, March 31, 1888; Hirschberg, 
Arch, fur klin. Chir., vol. xxxvii. p. 199; Weir, New^ork Medical Journal, May 26, 
1888 ; Marchant, La France Med., February 21, 1889; and Chapin,5New York Medical 
Journal, September, 1891, p. 12. 



PLATE XLVII 




Fjg# i.— Long Oblique Fracture of Tibia and External Malleolus. 




Fig. 2,-Fraeture of Cuboid. 



FRACTURES OF THE BONES OF THE EEC. 417 

acting through the external lateral ligament attached to the head of 
the fibula. In two of the reported cases (Stimson, Weir) the lesion 
was a separation of the epiphysis. In a number of the cases paralysis 
of the extensor and peroneal muscles and loss of sensation in the region 
supplied by the musculocutaneous branch of the peroneal nerve were 
noticed shortly after the accident, and in some persisted until the 
patients passed from observation. Weir and Marchant exposed the 
nerve in their cases and found it unbroken but apparently compressed 
by the edge of the fragment; the patients recovered almost completely 
from the paralysis. 

The upper fragment has been widely displaced upward in most of 
the cases, and it has usually been impossible to bring it fully back to 
its place, but it does not appear that any disability has resulted there- 
from. 

Treatment. The treatment consists in approximation of the frag- 
ments by bandaging aided by flexion of the knee to relax the biceps and 
plaster of Paris to prevent adduction of the leg. If peroneal paralysis 
exists it would probably be well to expose the nerve for some little 
distance above and below the fracture in order to reunite it if it is torn 
or to relieve pressure upon it. 

B. Fractures of the Shaft. 

These fractures are generally produced by direct violence, but Hop- 
pengartner x reports eighteen cases in young soldiers caused by a fall 
with a twist of the foot or in running ; in all the fracture was four 
fingerbreadths above the malleolus. The displacement is slight because 
of the support given by the tibia, and the diagnosis is made upon the 
localized pain and possibly crepitus and recognizable mobility or irregu- 
larity of outline. Occasionally symptoms indicative of injury to the 
cutaneous branch of the peroneal nerve are present, presumably by the 
violence which caused the fracture. 

Treatment. The only treatment needed is protection against external 
violence and movement of the lower fragment by twisting the foot ; 
this is conveniently given by a plaster or silicate dressing extending 
from the toes to the knee. It should be worn for about three weeks, 
and care should betaken for a fortnight longer to avoid muscular strain 
and lateral pressure by the foot at the ankle. 

C. Separation of the Lower Epiphysis. 

Poland 2 has collected four cases of this injury uncomplicated by 
fracture of the tibia. In three the injury was compound. One patient 
(Allis) died of tetanus, in one (Wright) the lower fragment became 
necrosed, and in the third (Poland) gangrene occurred on the third day 
after the application of a plaster dressing. In two other eases (speci- 
mens in the Middlesex and London Hospitals) three were extensive 
associated injuries amounting to dislocation of the ankle and requiring 
amputation. (See also Plate XLIIL, fig, 2.) 

1 Hoppengartnev : Zentralblatt Rir Chir., 1907, p. 1157. 

-Poland: Loc. cit., p. StiO. 

27 



CHAPTER XXVI 



FRACTURES OF THE BONES OF THE FOOT. 



1. FRACTURES OF THE ASTRAGALUS. 

These are commonly the result of falls from a height, the bone 
being broken between the calcaneum and the tibia, and the lesion being 
frequently associated with fracture of the calcaneum and with disloca- 
tion at the ankle and fracture of the fibula ; in other cases the force 
acts transversely. 

The direction and extent of the line of fracture vary greatly; the 
bone may be divided transversely, or longitudinally, or horizontally, 
or obliquely, or into several pieces, and the fragments may be widely 
separated and dislocated. 

Fig. 258. 




Fracture of the astragalus through the lower articular surface. 

When there is no displacement or external wound the diagnosis may 
be very difficult, because the symptoms are not distinctive and indicate 
only severe injury to the foot, pain, swelling, inability to bear the weight 
of the body on it, and perhaps crepitus on handling or flexing and 
extending it. The diagnosis must be made by exclusion of other 
injuries, by localized pain, and possibly by recognition of a displaced 
fragment, or of independent mobility of the head of the bone. I have 
once found it by the arrays, in combination with fracture of the os 
calcis and without displacement, when unable to recognize it clinically. 

When there is no displacement treatment is directed simply to immo- 
bilize the joint and control the inflammation ; a plaster bandage should 

418 



FRACTURES OF THE BONES OF THE FOOT. 41!) 

be applied, especial attention being given to the position of the foot, 
which should be at right angles to the leg in the antero-posterior plane 
and without inversion or e version. 

If a fragment is broken from the upper articular surface of the body 
it should be removed. If the neck has been broken and the head dis- 
placed it should be restored to its place, by an incision if necessary, or 
removed if it is found to be completely detached. If, in addition, the 
body has been rotated in its socket it must be readjusted, or, that failing, 
removed. If the body should prove to be crushed or comminuted its 
total excision, with or without the head and neck, will probably yield 
a much better functional result than conservative treatment. 

In compound fractures by direct violence removal of the astragalus 
is indicated because functional result is likely to be better than after 
even successful conservative treatment. 

Fracture of the Processus Posticus. 1 

This is the portion of the posterior border which lies between the 
groove for the tendon of the flexor longus pollicis and that for the ex- 
ternal lateral ligament. This fracture was first mentioned by Cloquet 
in 1844, but the correct interpretation of the small piece of bone fre- 
quently found in this place has been asserted by the anatomists to be a 
developmental vagary, the abnormal persistence of a small nodule which 
appears in the second month between the tibia and the astragalus. 
They term it the os trigonum. According to Lilienfeld, the os tri- 
gonum when present is almost always found on both limbs, and he 
claims to have observed 12 cases of fracture, 5 of them associated 
with fracture of the calcaneum. The diagnosis was made on x-ray 
findings with local tenderness on pressure and swelling. 

2. FRACTURE OF THE CALCANEUM. 

This bone may be broken by a fall upon the foot from a height, by 
contraction of the muscles attached to the tendo Achillis, by direct vio- 
lence, and by forcible inversion of the sole of the foot. The extent and 
position of the fracture vary with the causes. 

The forms of fracture 2 of the body of the bone may be grouped as 

(1) Separation of a large heel piece comprising the posterior half; 

(2) fracture of the anterior portion, often splintered ; (3) a general 
crush, mainly of the centre or anterior two-thirds. (Plates XL VIII. 
and XLIX.) The cause in most cases is a fall upon the feet. 

Symptoms. The symptoms of a vertical or crushing fracture are 
somewhat indefinite, and the diagnosis is not always easy, as is shown 
by the fact that surgeons so experienced as Malgaigne, Bonnet, Huguier, 
and Legouest have mistaken the injury for fracture of the fibula or 
ankle. The symptoms are increase of its transverse diameter (which. 
however, may be completely masked by the swelling below and about 
the malleoli), flatness of the sole and approximation to it oi' the mal- 

' Lilienfeld : Arch, fur Win. Chir., vol. 78, p. 929, 

z Sec also Cabot and Binney : Annals of Surg., January, L907, p. 51. 



420 FRACTURES. 

leoli, especially of the internal one. pain, and loss of function. Crepi- 
tus is either absent or obscure ; abnormal mobility may be recognized 
by moving the posterior portion laterally. Pain is caused by direct 
pressure and by a voluntary effort to 'make plantar flexion against 
resistance at the toes. The tendo Achillis feels less tense when pressed 
upon, and the depression on each side of it is obliterated by swelling. 
The deformity of the heel is best recognized when compared with' its 
fellow from behind while the patient is kneeling. 

Treatment. The treatment is immobilization, preferably with mas- 
sage, for about three weeks ; then passive motion, to be continued until 
the end of the second month. Cabot and Binney suggest the possible 
advisability in fractures with a large heel fragment of over-correcting 
the displacement by drawing the heel downward and forward. Cotton 
and Wilson 1 did this by passing a stout steel pin across in front of 
the insertion of the tendo- Achillis and forcing the posterior fragment 
forward and downward ; they avoid recurrence of the displacement by 
fixing the foot in plantar flexion so as to relax the muscles of the calf. 
Becker 2 passed a strong elevator transversely through the foot close 
beneath the fragments and forced them upward, and then fixed them 
in place with a long nail driven through them from the back of the 
heel. 

When the direction of the violence with reference to the axis of the 
leg is such that the foot is adducted or inverted by it, the strain is 
brought upon the external lateral ligament and the sustentaculum tali, 
with the result of producing fracture of the fibula as described on page 
413, or rupture of the external lateral ligament, or avulsion of a scale 
of bone from the side of the calcaneum where the ligament is inserted, 
or fracture of the sustentaculum tali. 

With the first of these we have not here to deal. A case of avulsion 
of a scale of bone came under my observation at the Presbyterian Hos- 
pital in 1880 ; the patient had fallen from a height of ten feet, striking 
upon his left foot. I saw him on the following day and found the foot 
and ankle much swollen, with obscure crepitus and pain on manipulation 
of the side of the heel below the outer malleolus. The swelling sub- 
sided under lead and opium lotions, and in a few days I could distinctly 
make out a movable flat fragment evidently detached from the outer 
side of the calcaneum below the malleolus. The movements of the 
foot and ankle were normal and painless except when the peroneal 
muscles were made to contract, then pain was felt below the external 
malleolus. The sheath of the tendons of these muscles was swollen 
below and behind the malleolus. 

Fracture of the sustentaculum tali was first described by Abel. 3 
In his first case the injury was thought to be a Pott's fracture of the 
ankle, and its real character was disclosed at the autopsy. The patient 
was a young man who in 'dismounting from a horse slipped on a stone 
and turned his foot forcibly inward. He attempted to walk, and the 

1 Cotton and Wilson : Boston Med. and Surg. Jour., Oct. 29, 1908. 

- Becker : Ztlblatt f ur Chir., 1903, p. 112. 

:; Abel : Archiv. fur klin. Chirurgie, 1878, vol. xxii., p. 396. 



PLATE XLVUI 





Fig 1.— Fracture of Os Caleis. (Cabot. 




Fig. 2.— Fracture of Os Caleis. ^Cabot.1 



FRACTURES OF THE BONES OF THE FOOT. 421 

position of the foot then changed instantly to marked valgus. A lon- 
gitudinal wound three inches long below the external malleolus opened 
the ankle-joint and the joint between the astragalus and calcaneum. 
There was tenderness on pressure below the internal malleolus, and on 
the fibula above the external malleolus. These symptoms together 
with the apparent broadening of the ankle and eversion of the foot led 
to the erroneous diagnosis mentioned. Erysipelas set in and the patient 
died on the fifteenth day. 

The fibula and tibia were found uninjured, the sustentaculum tali 
broken off, and the external lateral ligament divided in the line of the 
wound. 

Abel afterward saw two cases in which he thought this injury had 
been received some time before. In both the foot had been violently 
inverted, and in one the sustentaculum tali seemed to be doubled in 
size. The symptoms, primary and ultimate, corresponded to the fol- 
lowing, which he gives as diagnostic of the injury. 

1. The mode of production : forcible inversion of the sole of the foot. 

2. The immediate change in the position of the foot, from inversion 
to eversion, and the permanent sinking of the inner border of the foot 
and internal malleolus (valgus). 

3. Shortening of the heel by slight displacement of the calcaneum 
forward ; this can be best recognized by measuring from one malleolus 
to the other around the heel, and was verified by experiment. 

4. Pain and disability. 

The foot should be immobilized in a plaster bandage or splints with 
the sole sufficiently inverted to favor reunion of the fragments, but 
without lengthening of the external lateral ligaments if they have been 
torn. 

Fracture by muscular action, contraction of the soleus and gastroc- 
nemii, has been observed a number of times. Malgaigne collected 
eight cases, rather briefly reported ; in two the fracture was caused by 
a misstep, and in five by a fall upon the feet, in two of which it is 
noted that the patient alighted upon the ball of the foot. The fracture 
seems to take place always behind the astragalus and sometimes to 
separate only a portion corresponding to the insertion of the tendo 
Achillis. The displacement in some cases was slight, in others extreme, 
four and one-half inches from the lower edge of the fragment to the 
bottom of the heel in Constance's 1 case, in which, nevertheless, the 
patient made a good recovery with perfect use of the limb, although 
the displacement persisted. 

In a case reported by Anningson 2 the mechanism of the fracture 
seems very clear. A woman, forty-two years old, after stepping down 
from a doorway to the sidewalk, a distance of about six inches, cried 
out that she had "put out her ankle." She walked home slowly, a 
distance of one hundred yards. A fragment of bone was found two 
and a half inches above the heel in the line of the tendo Achillis which 
was lacking below it ; its lower edge was a little above the level of the 

1 Constance: American Journal of the Medical Sciences, L892, p. 222, quoting from an 
EiJglish journal. 

2 Anningson : British Medical Journal, 1878, vol. i. p. L28, 



422 FRACTURES. 

lower end of the internal malleolus ; it measured one inch transversely 
and "had been torn off the posterior surface of the os calcis where a 
cavity could be felt. The whole depth of the bone had not been torn 
away, but only the upper three-fourths, and the inferior edge of the 
fragment was tilted backward. The usual treatment of ruptured tendo 
Achillis was adopted," and eight weeks afterward the patient was able 
to walk without limping and complained only of some loss of spring. 

I have seen a similar fracture, but with less displacement of the frag- 
ment, caused by jumping from a boat, the fracture apparently occurring 
as the patient alighted on his toes. In another the patient while bend- 
ing forward was struck upon the back of the leg by a falling beam ; 
the posterior part of the fragment, as shown by a skiagram, was dis- 
placed upward three centimetres, but its anterior portion remained in 
contact with the os calcis. (Plate XLIX.) 

The foot should be maintained in the "position of complete plantar 
flexion, and it is sometimes advisable to flex the knee also. This can 
be done by a plaster dressing, or an anterior splint, or a shoe with a 
cord extending from its heel to a band about the upper part of the leg 
or the lower part of the thigh. Gussenbauer 1 successfully treated a 
case by nailing the fragment in place. 

3. FRACTURES OF THE SCAPHOID. 

Those which were formerly deemed very rare have been shown by 
the x-rays to be not very uncommon. Trippold collected 43 cases 
including 2 seen by Jacobsthal 2 , and Deutschlander 3 reported 5 per- 
sonal cases in 3 of which the fracture was caused by a twist of the foot 
in young girls. Finsterer 4 collected 22 cases, 2 of them personal, and 
Hoffmann (Ibid. p. 217) added another. Of these latter, 5 were caused 
by direct violence, the others by a fall, often from a moderate height, 
alighting upon the ball of the foot. The mechanism is apparently 
compression between the head of the astragalus and the cuneiform, 
possibly with forced flexion of the medio-tarsal joint. 

The lesion is sometimes a crush of the inferior and outer portion, 
sometimes a splitting into two or more fragments, and sometimes only 
a breaking off of the tubercle (see below). The symptoms are marked 
prominence of the inner portion of the bone on the dorsum and inner 
side of the foot, and great tenderness when this prominence is pressed 
upon. The inner side of the foot was also thought to be shortened. 
Finsterer thinks a characteristic symptom is the fact that while 
longitudinal compression of the foot, from the toes to the heel, causes 
great pain, the weight of the body in standing on the foot causes much 
less. Two-thirds of the cases were only recognized after a long inter- 
val with the aid of the .r-rays. 

The treatment suggested is to press the mesial fragment back inro 

1 Gussenbauer : Centralblatt far gesammte Therapie, June, 1888. 

2 Jacobsthal: Ztlblatt fur Chir., 1907, p. 604. 

3 Deutschlander : Arch, fur klin. Chir., 1907, vol. 83, p. 55. 

4 Finsterer: Beitrage zur klin. Chir., 1908, vol. 59, p. 99. 



FRACTURES OF THE BONES OF THE FOOT. 423 

place while the gap between the astragalus and the cuneiform is en- 
larged by traction on and abduction of the front of the foot. In two 
cases Deutschlander removed the bone. 

Some of the old cases showed marked evidences of chronic arthritis 
in the medio-tarsal joint. 

Haglund l describes fracture of the tubercle of the scaphoid caused in 
adolescents by muscular action, dancing ; he says it may result 
promptly in pes valgus. The occasional presence of a sesamoid bone 
in the tendon of the tibialis posticus (os tibiale externum) may be mis- 
taken for fracture of the tubercle. 

4. FRACTURE OF THE CUBOID. 

The only case of which I know is the one shown in plate XLVIL, a 
patient of the Hudson Street Hospital. The fracture was caused by a 
blow on the outer side of the foot ; crepitus was distinct on pressure of 
the fragment against the cuboid. 

5. FRACTURES OF THE METATARSAL BONES. 

These were formerly thought to be usually the result of direct vio- 
lence, and consequently often associated with contusion or laceration 
of the skin, even when the fracture was not compound. But Robert 
Jones 2 broke his fifth metatarsal near its base while dancing, and 
within a few months subsequently saw three cases similarly produced. 
And Tobold 3 reports over seven hundred cases observed in soldiers, 
almost all caused by indirect violence, as marching, jumping, etc. 
The second was the one most frequently broken, then the third. Lilien- 
feld 4 " has seen several cases of fracture of the extreme tip of the base 
of the fifth metatarsal caused by inversion of the foot, presumably 
through the pull of the peroneus brevis, and Wharton 5 reports three, 
caused by a twist of the foot in two and by a fall in one. 

There is but little tendency to displacement except when several 
bones are broken at the same time, and the usual displacement is of 
the broken end of either fragment toward the dorsum of the foot. 

The diagnosis is made by localized pain, abnormal mobility and 
crepitus when the first or fifth is broken, and pain when the corre- 
sponding toe is pressed bodily backward against the metatarsus. 

A simple fracture is not a serious injury, its course is uncomplicated, 
its result favorable ; but a compound fracture may lead to much bur- 
rowing of pus, necrosis of the fragments, and grave inflammatory com- 
plications, and the treatment should be directed actively to their 
prevention; if suppuration becomes profuse the freest possible drainage 
should be provided and counter-openings made on the sole or dorsum 
as the case may require. 

1 Haglund : Zentralblatt fur Chir., 1907, p. 327. 

2 Jones : Annals of Surgery, June, 1902. 

:J Tobold: Deutsche milltararztl. Zeitschrift, 1903, Part 9. abst. in Centralblatt t'iir 
Chir., 1904, p. 439. 

* Lilienfeld : Arch, fur klin. Chir., vol. 78, p. 929. 
& Wharton : Annals of Surg. May, 1908, p. S24. 



424 FRACTURES. 

The limb and foot may be supported upon a moulded spliut of plas- 
ter, felt, or pasteboard, and secured to it with a roller-bandage. In 
compound fracture the gauze dressings will immobilize the fragments 
sufficiently. 

6. FRACTURES OF THE PHALANGES. 

These are caused by direct violence and are usually compound, and, 
as in similar injuries of the hand, may be the starting-point of very 
serious inflammatory complications. Immersion of the foot in a bath 
containing 1 or 2 per cent, of carbolic acid once or twice daily for an 
hour each time is a valuable means of arresting commencing inflam- 
mation. 

The dressings of a compound fracture will immobilize the toe suffi- 
ciently, and in a simple fracture it is usually sufficient to place the foot 
on a splint. If it is thought desirable the toe itself may be steadied 
by strips of adhesive plaster applied longitudinally to its dorsum and 
sides, or it may be made fast to the adjoining ones. 



DISLOCATIONS. 



CHAPTER XXVII. 

GENERALITIES. 

A dislocation is a permanent, abnormal, total or partial displaee- 
ment from each other of the articular portions of the bones entering 
into the formation of a joint. 

The term diastasis is employed to indicate a direct separation, tem- 
porary or permanent, of articular surfaces, without lateral gliding of 
one upon the other, as when the pubic bones separate at the symphysis, 
or the tibia and fibula are torn apart, or in some injuries of the spinal 
column. 

If the displacement is only momentary, the parts immediately return- 
ing to their normal relations, the injury is classed as a sprain. 

When a coexisting wound of the soft parts establishes communication 
between the outer air and the cavity of the joint, the dislocation is said 
to be compound ; and when there exist associated lesions of the joint or 
neighboring tissues so extensive or peculiar as to present special indi- 
cations or create special difficulties in treatment, such as fracture or 
laceration of vessels, nerves, or integuments, it is said to be complicated ; 
under other circumstances it is described as simple. 

When the articular surfaces are so far displaced that they no longer 
touch each other, or that they touch only by their edges, the dislocation 
is said to be complete ; if the displacement is less, it is called an incom- 
plete dislocation or subluxation. Incomplete dislocations are frequent 
in the ginglymoid and arthrodial joints, and the controversy as to their 
frequency or infrequency in the enarthroses has arisen not from any 
doubt as to the nature of the new relations of the articular surfaces to 
each other or of the extent of the displacement, but solely from differ- 
ences in definition, some authors maintaining that only those dislocations 
should be deemed complete in which the head of the bone has entirely 
left its bony socket, and all those incomplete in which any portion of 
the head remains within the area bounded by the rim of the socket, 
whether portions of the articular surfaces are in contact with each other 
or not. Under that definition many dislocations of the shoulder and 
of the hip would probably have to be classed as incomplete, if the exact 
relations of the bones could be determined ; and as such accuracy of 
diagnosis would rarely be attainable, and the doubtful cases would not 
differ clinically from those in which the displacement is greater, the 
adoption of such a classification would serve only to embarrass and 
obscure. It seems to me much simpler and more practical, even if 
somewhat arbitrary, to call all traumatic dislocations of the hip ami 
shoulder complete in which the centre of the head of the bone has 
passed beyond the rim of the socket. The incomplete dislocations 
would then be exceptional, practically only those in which a portion o\' 
the rim of the socket is broken off and pushed aside by the displaced 



428 DISLOCATIOSS. 

head, as in a case mentioned by Robert l in an animated discussion of 
this subject before the Societe de Chirurgie. 

In the great majority of cases the dislocation is of a single joint only, 
but occasionally two or more joints may be simultaneously dislocated, 
and the injury is then said, according to circumstances, to be bilateral, 
double, or multiple. When a symmetrical bone, having joints on both 
sides of the median line of the body, as the lower jaw or a vertebra, 
suffers dislocation of these joints, the injury is called bilateral or double, 
and the same terms are also applied to symmetrical dislocations on op- 
posite sides of the body, as of both shoulders or both hips. When 
both ends of a bone are dislocated, as has been observed in the clavicle, 
ulna, and fibula, the dislocation is said to be double or total. 

Multiple dislocations are those in which two or more bones are simul- 
taneously dislocated, as two fingers, a shoulder and a hip. Some 
authors include under this term those dislocations which others term 
total. 

A method of nomenclature accurately descriptive of the different 
varieties of dislocation has not been established. As a general rule, 
subject, however, to some exceptions, the bone which is more distant 
from the trunk or median line of the body, the one that is generally 
moved upon the other, is said to be dislocated ; thus a dislocation at the 
hip, at the shoulder, is called a dislocation of the femur, of the humerus. 
Or the joint alone is named, as a dislocation of the elbow, of the hip, 
of the shoulder. As an example of the exceptions may be mentioned 
dislocation of the outer end of the clavicle, a term universally preferred 
to dislocation of the acromion. 

The same lack of uniformity appears in the names given to the vari- 
ous dislocations that may occur at the individual joints, and the prac- 
tice has grown up of using in each case such a name as may most 
readily and accurately indicate either the general character of the dis- 
placement or some important special feature connected with it. When 
the name of the joint is used, and a term indicating direction is added, 
as dislocation of the elbow backward, forward, to the inner or to the 
outer side, the latter denotes the direction in which the distal member 
of the joint has been displaced. Whenever the use of the name of the 
joint would give rise to ambiguity, it is common to prefer the name of 
one of the bones constituting it, as a dislocation of the radius and ulna 
backward, instead of dislocation of the elbow backward. Strictly speak- 
ing, it is true that this might be mistaken for a dislocation at the wrist, 
and that, therefore, it would be well to add " at the elbow," but cus- 
tom has so well established the meaning of the different terms now in 
use that in practice such a mistake would hardly be made. Other dis- 
locations, again, have received names denoting the relations of the dislo- 
cated bone to certain muscles or bones, as subcoracoid or subpectoral 
dislocation of the humerus, and dislocation of the (head of the) femur 
upon the dorsum of the ilium or into the obturator foramen. 

The primitive or primary displacement is the one immediately effected 
by the causative violence which produces the dislocation ; if the dislo- 
cated bone afterward shifts to another position, the displacement is said 
1 Robert : Bull, de la Societe de Chirurgie, January 19, 1853, p. 389. 



GENERALITIES. 



420 



to be consecutive or secondary. This shifting of the position of the 
dislocated end sometimes has very important consequences as regards 
treatment, because the end of the bone may thereby be removed from 
its position opposite the rent in the capsule through which it escaped 
from the cavity of the joint, and it may need to be brought back to 
that position before it can be replaced in the joint. 

In the great majority of cases a dislocation is produced suddenly by 
external violence or by muscular action, or by the two acting together 
upon a healthy joint, and when thus produced it is called traumatic. 
In other cases the joint has been altered by disease previous to the 
occurrence of the dislocation, and this latter is effected by the gradual 
action of the muscles or even by gravity ; these are known as sponta- 
neous, and present many varieties. (See Chapter XXXVI.) A third 
class, congenital dislocations, is composed of those in which the dislo- 
cation occurs during intra-uterine life, presumably as the result of a 
malformation or defective development. Dislocations produced during 
delivery are traumatic. The second and third classes will be sepa- 
rately considered. (See Chapters XXXV. and XXXVI.) 

Statistics. Compared with other surgical injuries, dislocations are 
infrequent ; the proportion to fractures is about 1 to 10. 



Dislocations at the Hudson Street Hospital, New York, 1894-1905. 
Hospital and Dispensary. 

191 



Hip ; dorsal 

thyroid 

Knee 

Semilunar cartilage . . 
Patella, outward . . . 
Head of fibula .... 

Ankle 

Astragalus 

Subastragaloid .... 
Metatarsus and phalanges 



Lower jaw 

Vertebra* 

Chondro-sternal . . . . 
Sacro-iliac synchondrosis . 



12 
13 

9 

1 

5 

5 

5 
17 J 



Clavicle, outer end ... 69 " 

sternal end 12 

Shoulder 617 

Elbow 156 

Head of radius l 18 

Ulna, upper end * . . . . 13 

lower end 8 

Carpus 7 I- 

trapezium 1 

semilunar 5 

scaphoid 3 

os magnum 1 

Metacarpal 80 

Metacarpophalangeal and 

phalangeal 378 



61 
6 

1 I 
2 j 
1527 



Lower extremity, 89 5.82 per cent. 



Upper extremity, 1868 89.59 per cent. 



Head and trunk, 



70 4.58 per cent 



Includim 



jociated fracture, 



430 



DISLOCATIONS. 



Table of 400 Recent Traumatic Dislocations (Kronlein). 1 
Hospital and Polyclinic. 



Joints. 



Hip 

Knee 

Foot 

Metatarso-phalangeal 

Shoulder 

I 

Elbow -j 

Wrist 

Metacarpophalangeal 
Interphalangeal . . . 
Sterno-clavicular . . 
Acromio-clavicular 

Lower jaw < 

Cervical vertebrae . . 



Kind. 



Iliac 

Obturator . . 

Pubic 

Lateral . . . . 
Patella out- ) 
ward ) 
backward 

Subcoracoid \ 
and axillary j 
Erecta . . . . 
Infraspinous . 
Of forearm . ) 
backward / 
Of radius . . . 
Dorsal of ulna 



Unilateral 
Bilateral . 



Sex. 



2 


1 


1 
3 


1 


L80 


23 


3 

1 




77 


17 



336 64 

400 



Age. 



o 


F. 


9. 

"i 
1 

53 

2 

14 

1 
1 
4 
5 

2 

"i 

3 


f 

M 
1 

"i 

1 

44 
1 

5 

"8 
1 

"2 

i 




3 

48 
4 

"i 

1 

"4 
2 


cr 
7 

iO 

1 

"l 
1 

"2 

35 

"i 
3 

... 

3 
1 




"i 

1 

19 
1 

1 


% 


2 
2 

1 

"(i 
1 
1 

"i 

44 


"l 
2 

"i 

2 

M 

5 

8 

"3 

1 
1 
1 


2 

1 


69 


— 

88 


65 


60 


48 


'23 


3 



400 



Totals. 



203 •) 

tr 

151 , 

27 
8 
6 

11 



400 



Percentages of 
frequency. 



1.7 



0.5 

0.7 



51.7 

27.2 

0.2 
6.7 
2 
1.5 

2.7 

2.5 
0.2 



Lower 

y extremity, 

20 = 5 

J 
1 



Upper 
extremity, 
369 = 92.2 



Trunk, 
11 = 2.8 



The following table summarizes the other two with Malgaigne's 
statistics of the Hotel-Dieu : 



Malgaigne, hospital 

Kronlein, hospital and polyclinic 
Stimson, hospital and dispensary 



491 
400 
1527 



Cases. Upper extremity 



85.7 per cent. 

92.2 

89.59 



Lower extremity. 



12.6 per cent. 



Trunk. 



1.6 per cent. 

2.8 
4.58 " 



These tables show the great relative frequency of dislocations of the 
upper extremity as compared with those of the lower. Each set of 
statistics shows that dislocation of the shoulder is far more common 
than that of any other joint, and that next in frequency come disloca- 
tions of the elbow. These two dislocations may be estimated as 
together comprising from two-thirds to three-fourths of all cases, 
excluding the phalanges. 

As between males and females, Malgaigne and Gurlt found the 
injury three times as frequent in the former as in the latter; Kronlein 
found it five times as great. Dislocations of the lower jaw are an ex- 
ception, being four times (Kronlein) as frequent in women as in men. 

Age. No age is exempt; dislocations have occurred as early as the 
moment of birth and as late as the age of ninety years. The relative 
liability to the injury at different ages is shown not by simply com- 
paring the number of cases observed at those ages, but by also com- 

1 Kronlein : Deutsche Chirurgie, Lief. 26, p. 5. 



GENERALITIES. 



43 1 



paring these numbers with the number of people at those ages living 
in the community where the observation is made. This comparison 
has been made by Kronlein for Berlin, with the following results : 

Frequency of Dislocations at Different Ages. 



Absolute frequency 

Relative number of people living 

Relative frequency as computed for equal ) 
numbers of people J 



1-10 


11-20 


21-30 


31-40 


41-50 


51-60 


61-70 


71-8 


44 


69 


88 


65 


60 


48 


23 


3 


1872 


1620 


2529 


1679 


940 


599 


282 


117 


10 


18 


15 


16 


27 


35 


35 


10 



From this it appears that a smaller proportion of individuals 
between the ages of one and ten, and seventy-one and eighty years 
receive dislocations than in any other decade of life ; and the highest 
proportions are found between the ages of fifty-one and sixty and 
sixty-one and seventy. It is further to be noticed that dislocation of 
the shoulder is very rare, and that of the elbow very common, before 
the age of twenty-one years. Kronlein's table shows that of 207 cases 
of the shoulder, in only two were the patients less than twenty-one 
years old, and that of 109 cases of the elbow 80 were no older, the age 
in 31 being between one and ten years, and in 49 between eleven and 
twenty years. Compared with fractures, it appears that the liability 
to dislocation is least during those periods of life in which the liability 
to fracture is greatest — that is, in infancy and youth and in old age; 
the latter part of this statement may need some modification, for while 
dislocations are rare after the age of seventy, they are relatively fre- 
quent in the preceding decade. The liability to each increases from 
adolescence through middle life. 



CHAPTER XXVIII. 

ETIOLOGY AND MECHANISM. 

Predisposing Causes ; Immediate Causes ; Recurrent or Habitual Dislocations. 

The causes of dislocation may be grouped in two classes : a. Pre- 
disposing ; b. Immediate or determining. 

A. Predisposing Causes. 

These are found in certain normal differences of form and function 
characterizing certain joints, and in accidental or pathological conditions 
that sometimes arise. 

The joint which is most frequently dislocated is the shoulder-joint, 
and it differs normally from others in the wide range and variety of 
motion made possible by its form, the laxity of its capsule, and the 
absence of any firm ligament to hold the bones closely together. A 
wide range of motion in one direction is not necessarily a circumstance 
favoring dislocation ; on the contrary, it may protect against it by 
making it difficult to bring into action the fulcrum which is furnished 
by the edge of the bone when it arrests the motion. In a young 
healthy person the elbow or knee cannot be dislocated by flexion, 
because the motion is finally arrested by broad contact of the soft parts, 
not by the edge of the joint; while, on the other hand, in each case 
extension is limited by the structures of the joint itself, and hyper- 
extension at once favors dislocation by rupturing those structures. A 
long range of motion in one plane does not make the joint insecure so 
long as the two bony surfaces rest squarely against each other, as they 
do in the hinge-joints ; but when the change of position makes this 
contact oblique, as in abduction of the arm, a displacing force exerted 
in the direction of the long axis of the bone is resisted only by the 
capsule. Under certain conditions, therefore, it may be said that free- 
dom of motion in a joint diminishes, and limitation of motion increases, 
the liability to dislocation. 

Dropsy of some joints favors dislocation by removing the obstacle 
which the necessity of creating a vacuum between the articular surfaces 
would otherwise interpose. (See Chapter XXXVL, Dislocations by 
Distention.) 

The destruction of the ligaments by violence or disease, and frac- 
ture or disease of the bony constituents of the joint, favor dislocation, 
and the fracture of an associated or parallel bone may have the same 
effect, as fracture of the ulna favors dislocation of the head of the 
radius. 



ETIOLOGY AND MECHANISM. 



B. Immediate or Determining Causes. 

A bone may be dislocated by (1) external violence applied (a) directly 
to it at or near its end, or (6) indirectly and at a distance from its end ; 
(2) by muscular action. 

1. External Violence. Dislocations by direct violence are rare, espe- 
cially if the class is restricted to those cases in which the violence falls 
upon only one of the bones forming the joint and forces it directly 
away from the other. Thus, the head of the humerus has been driven 
backward (subspinous dislocation) by a blow of the fist (Busch) or by 
a fall in which the front of the shoulder struck against the corner of 
a table (Krb'nlein), or inward by a fall upon the outer side of the 
shoulder, or even downward into the axilla by a force received upon 
and first breaking the acromion (Kronlein, Stimson). 

In dislocations by indirect violence the mechanism may vary greatly. 
The force in some cases is exerted directly along the long axis of the 
bone while the limb is in a position in which the articular surfaces do 
not rest squarely upon each other, and the head of the bone is driven 
out of its socket, as in some dislocations of the shoulder by a fall upon 
the outstretched (abducted) arm or by muscular action, or in disloca- 
tion of the outer end of the clavicle by a fall upon the shoulder. The 
mechanism is similar to that of the first form of dislocation by direct 
violence mentioned above. Or a much slighter force, favored by 
conditions of leverage established at the joint, tears the capsule or 
a ligament and produces a dislocation. This is the most common 
mechanism. The conditions of leverage are found at all points where 
normal movements are arrested or no movement permitted. The head 
or neck of a moving bone is arrested by the edge of the corresponding 
articular cavity, or by a projecting point of bone, or by a tense liga- 
ment or portion of capsule ; this at once becomes a new centre of 
motion, a fulcrum, and, the force continuing to act at the end of the 
bone or limb (the long arm of the lever), the head of the bone (or short 
end of the lever) is forced away abnormally. 

When the force is exerted in a direction in which normally no motion 
is permitted, as laterally at the elbow, ankle, or knee, it meets at once 
with greater resistance than that habitually found at the extremes of 
normal ranges of motion, and if it is great enough to overcome this 
resistance it is more likely to cause in addition other and perhaps 
extensive injuries of the soft parts or of the bones. 

Violence, then, acting in a given manner, may cause a fracture, a 
dislocation, or a sprain according to its force, the strength of the resist- 
ance oifered by the ligaments and the bones to which they are attached. 
and the prolongation of its action. 

2. Muscular Action. Contraction of the corresponding muscles can 
cause the dislocation of a sound joint in either of two ways : it can. by 
rapidly moving the limb, communicate to it a momentum which acts 
in the same manner as external violence and produces a dislocation 
when the normal limit of the range of motion is reached and condi- 
tions of leverage are established. A ease, probably of this kind, was 
28 



434 DISLOCATIONS. 

observed by Sedillot : l a woman, forty-six years old, who dislocated her 
shoulder by raising her arm to strike a blow. Or. secondly, the mus- 
cular contraction acts like external violence received at or near the end 
of the bone, or transmitted along its longitudinal axis, and draws the 
bone out of its socket. For this it is essential that one or two muscles 
should contract violently while the others that normally act upon the 
joint remain passive, or that the limb should be in such a position that 
the line of traction of the muscles is nearly parallel to the opposing 
articular surface. Instances of this kind are common at some joints ; 
dislocation of the lower jaw is commonly caused by muscular action 
in vawning'. laughing:, or vomiting, and other- have been caused in like 
manner at the shoulder and hip. and. very exceptionally, at other 
joints. As illustrative examples may be mentioned the following : 

A man, fifty-one years old, dislocated both shoulders (subcoracoid) 
by drawing himself up with his hands ; a painter dislocated his shoul- 
der while painting a ceiling : a woman, by trying to lift a heavy object 
from a shelf; a man. by trying to lift at arm's length a heavy book 
from the floor ; and a woman, by carrying a heavy load upon her head 
with both arms uplifted. 

Many cases have been reported in which dislocation has been caused 
by the convulsive contractions of individuals affected with epilepsy, 
tetanus, or uraemia, or poisoned with strychnine. In many of the 
cases reported as such the dislocation may have been caused by vio- 
lence received in falling during a lit or by striking the limb against 

■ . . . 

some object, but in a number of them the history positively establishes 

the ab.-ence of any other cause than the contraction of the muscles. 

In these cases, as in fractures by muscular action, it is unnecessary 
to suppose, and unwarranted to claim, that the strength of the capsule 
or ligaments is less than usual, or that the structure of the joint varies 
from the normal in such a way as to facilitate the production of the 
dislocation. 

The power of voluntary dislocation of one or several joint- has been 
occasionally observed. In a large proportion of the cases its appear- 
ance has followed the occurrence of a traumatic dislocation of the same 
joint, but in a few instances the history of the individual contained the 
record of no traumatism or diseased condition to which the peculiarity 
could be referred. 

C. Recurrent or Habitual Dislocations. 

Individuals are occasionally observed in whom dislocation of some 
one joint, commonly the shoulder, but also the hip, jaw. and clavicle, 
frequently recurs under the influence of some slight cause, and who 
have acquired this liability as the result of an ordinary traumatic dis- 
location, or of paralysis of one or more of the muscles of the joint, or 
of fracture. The first class will be considered in Chapter XXIX. ; of 
the others the following case, reported by Sir Astley Cooper.- will 

1 Sedillut : Diet. Enevclopedique. art. Luxations, p. 23. 
- Cooper : Di.slucatiuus and Fractures. Am. td.. 1S44. p. 9. 



ETIOLOGY AND MECHANISM. 435 

serve as an illustration: "A gentleman happened, as a junior officer 
on board his ship, to be plaeed under the orders of one of the mates 
when the captain was on shore, and for some trifling offence was 
punished in the following manner : his foot was placed upon a small 
projection on the deck, and his arm was lashed tightly toward the yard 
of the ship, and thus kept extended for an hour. When he returned 
to England he had the powec of readily throwing that arm from its 
socket merely by raising it toward his head, but a very slight extension 
reduced it ; the muscles were also wasted, as in a case of paralysis." 

The explanation is to be found in the loss of support occasioned by 
the diminution of the tonicity of the muscles which in such joints as 
the shoulder, take the place of short, firm ligaments and hold the 
articular surfaces in contact with each other, a loss which allows the 
bones to be separated by the action of gravity, or by an effusion into 
the joint, until the separation is arrested by the capsule. When thus 
separated, a slight force is sufficient to throw the head of the humerus 
past the edge of the glenoid cavity and produce a dislocation without 
rupture of the capsule. 

The cases of dislocation due to limited paralysis of peripheral origin 
must not be confounded with those sometimes accompanying the 
arthropathies that complicate some paralyses of central origin and 
some cases of central nervous disease without paralysis. In the latter 
the articular portions of the bones are absorbed in the progress of the 
disease, and thus even a joint the bones of which are normally held 
close together by ligaments becomes a loose one by loss of bone sub- 
stance. Strictly speaking, such cases in which the articular end of the 
bone has been entirely absorbed do not come within the definition of 
dislocation, but clinically it is proper and convenient so to designate 
them. (See Chapter XXXVI.) 

The unequal growth of parallel and associated bones, tibia and fibula, 
or radius and ulna, may cause dislocation at one or the other end. 

1 Cooper : Dislocations and Fractures, Am. ed., 1844, p. 9. 



CHAPTER XXIX. 

PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS; COMPLI- 
CATIONS ; AND THE PROCESS OF REPAIR AFTER REDUCTION. 

PATHOLOGICAL ANATOMY. 

As a traumatic dislocation consists in the forcible overcoming of the 
normal restraints upon the motion of the joint in one or more direc- 
tions^ restraints offered by the ligaments and capsule of the joint, it is 
almost invariably accompanied by rupture of a ligament or of the cap- 
sule. There is some reason to think that dislocation of the inferior 
maxilla may be an exception to this rule, but the lack of opportunities 
directly to examine such cases leaves the question in doubt. In enar- 
throdial joints, especially the shoulder, where the ligaments are loose 
and where the bones are held together by the tonicity of the muscles 
and the atmospheric pressure, such a change as dropsy of the joint may 
so annul the effect of the latter agent and overcome the former by filling 
the capsule with liquid that insinuates itself between the contiguous 
articular surfaces, that the head of the bone falls away from its socket 
and the joint becomes loose like that of a flail ; under such circum- 
stances dislocation may occur without rupture or laceration. 

The capsule of an enarthrodial joint is torn upon the side toward 
which the distal bone is displaced; in joints of other forms the liga- 
ments may be broken on either or both sides, the extent and character 
of the injury varying with the character of the force. The rent in the 
capsule may be limited in extent and simple in form, merely a longi- 
tudinal or transverse slit, or it may be irregular or may even involve 
the entire periphery. Instead of suffering a rent, the capsule may be 
torn away from the bone, sometimes bringing with it portions of the 
bone itself or remaining continuous with the periosteum stripped up 
from the shaft. Under similar conditions the position of the rent in 
the capsule is very constant, for it is determined by the posture of the 
head and the direction of the force. In addition to the laceration of 
the capsule and ligaments produced by the pressure of the bone, others 
may be caused by the tearing off of attached muscles that are put upon 
the stretch by the displacement. This may be effected by the avulsion 
of the tuberosities upon which the muscles are inserted : the bone yields, 
and the laceration, starting from the broken surface, extends across and 
through the adjoining soft parts. This is a frequent accompaniment 
of dislocation forward and downward of the shoulder ; the supra- 
spinatus and infraspinatus muscles, inserted respectively upon the 
upper and middle facets of the greater tuberosity of the humerus, are 
put upon the stretch and one or both are torn away from the bone. 

The soft parts overlying the capsule may be torn by extension of the 

436 



COMPLICATIONS OF RECENT DISLOCATIONS. 431 

rent in the capsule if they are closely adherent to the latter, or by the 
forcible passage through them of the displaced bone. The surrounding 
muscles on the side toward which the displacement takes place may be 
contused or torn by the passage of the bone, and those upon the oppo- 
site side by being put upon the stretch. Blood is freely extravasated 
into the cellular tissue from the ruptured vessels. 

The cartilages of incrustation may be bruised and sometimes chipped 
in the passage of the surfaces across each other, and projecting portions 
of bone, apophyses, or the rim of an orbicular cavity may be broken off. 

The bone itself seldom passes to any great distance from its normal 
position ; its progress is arrested by the ligaments and muscles that 
remain untorn and the resistance of the soft parts that it presses upon, 
and it comes to rest lying directly upon the adjoining bone or with some 
soft parts interposed. Its position, as taken in the primary displace- 
ment, may be changed by the renewal of external violence, by gravity, 
by a change in the position of the limb, or by the spasmodic contrac- 
tion of attached muscles, but the secondary position (" consecutive 
displacement ") is habitually determined by the resistance of untorn 
ligaments which constitute the fulcrum or pivot about which the bone 
turns. 

COMPLICATIONS. 

Other injuries, and severer or more extensive forms of those 
already mentioned, may coexist with a dislocation as complications. 
They include fracture of the bone, partial or complete rupture of 
large bloodvessels or nerves, and extensive laceration of the soft 
parts. To constitute a " complication " of the dislocation the associ- 
ated injury should be the direct or consecutive result of the original 
violence upon adjoining tissues, and should create special indications 
for, or difficulties in, treatment. A fracture of the leg caused by the 
same fall that dislocates the shoulder is not, in this sense, a " compli- 
cation " of the dislocation ; but a fracture of the ulna accompanying 
dislocation of the radius, or a fracture of the neck of the humerus 
accompanying dislocation of the shoulder is a complication, for the two 
injuries are associated in their origin and in their treatment. 

Bones. Not all fractures that coexist with dislocation of even the 
same bone are necessarily to be deemed complications, since some habit- 
ually accompany certain dislocations, may even not be recognizable 
clinically, and neither receive nor require special treatment. Such are 
fractures of apophyses or tubercles to which muscles are attached, and 
some fractures of a portion of the articular end of the bone or of the rim 
of an orbicular cavity. In others the dislocation is rather to be deemed 
a complication or incident of the fracture, since it is made possible by 
it, as in some fractures of the vertebra^ and in fracture of the olecranon 
with displacement forward (or upward) of the radius and ulna. 

Relatively common are those in which the force is exerted through 
the head of the bone upon the margin of the opposing articular sur- 
face, breaking off the latter ; the dislocated bone leaves the joint through 
the gap thus created, driving the fragment before it, or else tears the 
capsule and escapes in the usual manner. The commonest examples 



438 DISLOCATIONS. 

of this kind are found in fractures of portions of the rim of the glenoid 
and cotyloid cavities, and some fractures at the ankle with dis- 
placement of the astragalus. Others, that are closely analogous, are 
fractures of the coronoid process of the ulna or of the head of the 
radius, or of both, in dislocation backward of both bones. 

Bruising or deep indentation of the head of the bone by impact upon 
the edge of the socket has been noted several times at the shoulder and 
once by myself at the hip. It cannot be recognized clinically and is 
not known to have important consequences, but when the impact is 
along the anatomical neck of the humerus it may detach the head, and 
in two cases l the head of the femur has been split vertically ; in a third 2 
the head and neck Avere split longitudinally, apparently after disloca- 
tion had taken place. 

A very rare complicating fracture is that of the central part of the 
acetabulum when the head of the femur is driven through it into the 
cavity of the pelvis by great violence. 

Much more common, but seldom deserving to be classed as compli- 
cations, are those fractures by avulsion, already referred to, in which, 
ligaments or muscles being put upon the stretch, the bony prominences 
to which they are attached are torn off. Some of them may be looked 
upon as frequent accompaniments of certain dislocations, for example, 
fracture of the greater tuberosity of the humerus in dislocation of the 
shoulder forward and downward, and fracture of the internal epicon- 
dyle in dislocation of the elbow. 

The form in which the complication most seriously affects the treat- 
ment and prognosis is that in which the bone is broken completely 
across near the dislocated end. The commonest examples are found 
at the shoulder, where the line of fracture follows either the anatomical 
or the surgical neck, and the special difficulty in treatment arises from 
the smallness of the upper fragment, whereby it is made difficult or 
impossible so to act upon it as to return it to its normal position in the 
joint. In 68 cases of this kind collected by Thamhayn 3 14 were of the 
anatomical neck of the humerus, and of these in only 2 was the dislo- 
cation reduced ; while of the 46 cases in which the fracture occupied 
the surgical neck 20 were reduced. McBurney's recent (1893) method 
of reducing with the aid of a hook inserted into the fragment has 
greatly diminished the difficulty. The mechanism of the combined 
lesions is sometimes obscure, as regards its details, and varies in the 
different cases, the dislocation sometimes preceding and sometimes fol- 
lowing the fracture, and perhaps sometimes occurring simultaneously. 
In a specimen figured by Kronlein the head of the humerus, after 
fracture of the anatomical neck, has been completely reversed and lies 
wedged between the tuberosities. 

Bloodvessels. Injury of a large bloodvessel adjoining a dislocated 
joint (the dislocation not being compound) is a comparatively rare acci- 
dent, and one that depends either upon the close relations of the vessels 

1 Birkett : Medico-Chirurgical Transactions, 1869, vol. Hi. p. 133. Moxon : Medical 
Times and Gazette, 1872, vol. i. p. 96. 

2 Riedel : Beilage zum Centralb. fur Chir., 1885, p. 92. 

3 Thamhayn : Schmidt's Jahrbuch, 1868, vol. cxl. 



COMPLICATIONS OF RECENT DISLOCATIONS. 439 

and the bones, as at the shoulder and knee, or upon violence so great 
as to displace the bone to a greater distance than usual, or in an 
unwonted direction. 

In most of the recorded cases the dislocation has been of the shoul- 
der, inward and forward, and the lesion has consisted either in the 
rupture of a large arterial branch, the anterior circumflex or the sub- 
scapular, at or near its origin, or in such stretching of the axillary 
artery that its inner and middle coats have been torn across, the outer 
one remaining undivided, or, more rarely, in rupture of the main vein. 
The injury may result in the immediate formation of a traumatic aneu- 
rism or in the gradual formation of an encysted one, or in gangrene of 
the distal portion of the limb. In some of the recorded cases it is not 
possible to determine whether the injury to the vessel was the imme- 
diate result of the dislocation or of the efforts to reduce it. 

The symptoms vary greatly, but, except at the shoulder, are not 
likely to leave any doubt concerning the nature and details of the 
injury. Injury to the inner and middle coats alone may in some cases 
be recognized by the immediate cessation of the brachial and radial 
pulse, in others only by the subsequent gradual formation of an aneu- 
rism. In other cases the prompt appearance and rapid growth of a 
fluctuating swelling in the axilla, perhaps accompanied by extensive 
ecchymosis and alarming symptoms of collapse or shock, sufficiently 
prove the fact of an internal hemorrhage ; but the source of the bleed- 
ing, whether from an arterial branch, the main artery, or the vein, may 
remain in doubt, for the radial pulse may persist even when the hem- 
orrhage comes directly from the axillary artery. The subject will be 
more fully discussed in Chapter XXXIV. 

In a case observed by Korte, 1 this complication accompanied a dis- 
location of the shoulder caused by a blow received upon its upper sur- 
face while the arm was abducted ; the dislocation was spontaneously 
reduced before the arrival of the surgeon, and probably the displace- 
ment was only slight. An aneurism formed, and was opened under the 
impression that it was an enlarged lymphatic gland. The autopsy indi- 
cated that the lesion was avulsion of the anterior circumflex artery at 
its origin, and showed also that the inner and middle coats of the 
axillary artery were torn transversely at a higher point, but the calibre 
of the vessel w r as not thereby obstructed. 

The following cases illustrate other varieties : 

Mr. J. W. Turner 2 reported two cases of rupture of the popliteal 
artery complicating dislocation of the knee. In the first a man. twenty- 
four years old, fell from a height of thirty feet and sustained a com- 
pound dislocation of the knee, the condyles of the femur projecting 
through the integument of the ham. The limb was immediately ampu- 
tated, and the two inner coats of the popliteal artery were found to be 
ruptured, the outer coat remaining untorn. 

In the second case a middle-aged woman fell while carrying a heavy 
burden on her back. There was found a dislocation o\' the knee to- 
gether with a wound in the ham, through which, it was said, the con- 

1 Korte: Arehiv fur kliniscke Chirurgie, 1882, p. (>:u>. 

2 Turner: Transactions of the Edinburgh Medico-Chirurgical Society, vol. iii. p. 308, 



440 DISLOCATIONS. 

dyles of the femur had projected. There "was no bleeding; the limb 
became greatly swollen, and the patient died on the tenth day. The 
artery and vein were found to have been torn completely across. 

Dr. M. Goldsmith 1 reported the case of a man, forty years old, who 
suffered a dislocation of the left femur ; " the head of the bone being 
thrust under Poupart's ligament overrode the margin of the pelvis in 
such a manner as to underlie the femoral artery ; it remained unreduced 
for two months, when he came under observation with a diffused swell- 
ing occupying the groin, filling the iliac fossa, and extending to the 
middle of the thigh ; feeble pulsation ; tumor appeared a few days after 
the accident ; pain severe ; diagnosis, aneurism ; treatment, ligature of 
the common iliac artery ; death on fifth day." The femoral and exter- 
nal iliac arteries were perforated to the extent of an inch on the pos- 
tero-external aspect ; the head of the femur lay in the cavity of the 
aneurism. 

Cases also have been reported of rupture of the anterior and poste- 
rior tibial arteries in dislocation of the ankle; and Sedillot 2 published 
one in which the brachial artery was ruptured at the elbow by being 
stretched over the end of the humerus in a dislocation of the radius 
and ulna backward. 

Nerves. Injuries of the nerves may be demonstrated by direct exami- 
nation or inferred from the symptoms. Examples of the former are 
uncommon, and in some of the latter it may remain in doubt whether 
the nerves were injured by the displacement of the bone, or by the 
efforts to reduce the dislocation, or by the independent action of the 
violence upon them. It is asserted 3 that a fall upon the hand or 
shoulder, without lesion of the skeleton, is competent to cause palsy of 
the arm ; hence, it is not always to be inferred that a palsy following 
a dislocation has been caused by the pressure of the head of the bone 
upon the nerves, and this is especially true of those cases in which a 
blow has been received directly upon the shoulder, and the deltoid 
alone is paralyzed. 

The injury may be a complete rupture or laceration of one or more 
nerve trunks, or a contusion with extravasation of blood about the nerve 
and amid its fibres, or a neuritis originating in an injury of some lesser 
nerve and extending thence to the main trunk, or an inflammatory pro- 
cess extending to the nerve and causing its compression by newly 
formed connective tissue, or simple compression by the displaced bone. 

Rupture or laceration of the nerve is caused by violent pressure 
against it of the displaced end of the bone, and, in the case at least of 
the larger trunks, it appears commonly to be associated with extensive 
laceration of the other soft parts, including even the overlying skin. 
Contusion of the nerve may be produced in the same manner, and then 
represents a less degree of the same injury, or by compression of the 
nerve between the displaced bone and an adjoining portion of the 
skeleton, as between the head of the humerus and the wall of the 
thorax. 

1 Goldsmith : American Journal of the Medical Sciences, July, 1860, p. 30 ; abstract 
from the Louisville Medical Journal. February, 1860. 

2 Sedillot : Diet. Encyclopedique, art. Luxations, p. 261. 

3 Weir Mitchell : Injuries of Nerves, p. 99. 



COMPLICATIONS OF RECENT DISLOCATIONS. 441 

The symptoms vary with the character of the injury ; laceration is 
immediately followed by motor paralysis and loss of sensation in the 
region supplied by the nerve, which are permanent or persist until the 
integrity of the nerve is restored ; in other forms of injury there are 
varying degrees of paralysis and loss of sensation, numbness, pain, 
alteration of local nutrition, and other symptoms of neuritis, limited 
at first to the nerve directly injured, and afterward perhaps extending 
to others. In many of the recorded cases a cure has followed the 
systematic use of electricity. 

The statistics of the Friedriclr's Hospital collected by Holm l show 
that of 112 cases of dislocation of the shoulder there was general paral- 
ysis of the arm in 7, and paralysis of the deltoid alone in 10. In one 
of them all the muscles supplied by the median nerve were paralyzed, 
while those supplied by the musculo-spiral were unaffected. This is a 
very much larger proportion than I have observed. 

The recorded cases of rupture of a nerve verified by direct exami- 
nation are few ; the following are examples of different forms : 

Hilton 2 examined the body of a man who died thirteen weeks after 
having received a dislocation of the shoulder into the axilla ; the del- 
toid was much atrophied, the circumflex nerve was small and was 
" distinctly lacerated, but its actual condition was changed by some 
strong cellular adhesions, fixing it with the radio-spiral nerve and the 
axillary artery to the inner surface of the subscapularis muscle." 
Bouley 3 presented to the Societe Anatomique a specimen of complete 
dislocation outward of both bones of the forearm at the elbow, with 
fracture of the outer condyle of the humerus, caused by a fall upon 
the elbow from a height of twenty-four feet. The patient refused 
amputation and died twenty days after the receipt of the injury. 
" The lateral ligaments of the elbow were entirely ruptured, both 
bones of the forearm were situated external to the lower end of the 
humerus, and the ulnar nerve was lacerated at the level of the articular 
surface." 

Holl 4 found in the dissecting-room a cadaver with a marked deformity 
of the elbow, and on examination it appeared that the individual had 
suffered fracture of the upper end of the ulna and dislocation of the 
head of the radius upward and inward, and that the ulna artery and 
ulnar and median nerves had been completely divided and had not 
reunited. In 9 reported cases of the same combination of fracture and 
dislocation the musculo-spiral nerve has been injured. See Chapter 
XLYI. 

Midler, 5 seven months after dislocation of the shoulder which had 
been easily reduced and which had been followed by gradual paralysis 
of motion and sensation in the arm, found, by an axillary incision, the 
artery and main nerves tightly compressed by a cicatricial band about 
a quarter of an inch wide. On division of the band pulsation at once 

1 Holm : Schmidt's Jahrbuch, vol. cxxi. p. 82. 

2 Hilton : Guy's Hospital Reports, 1S47, vol. v. p. 93. 
8 Bouley: Bull, de la Soc. Anatomique, 1S37, p. 101. 
* Holl : Mediein. Jahrbuch, Wien, 1880, p. 151. 

& Miiller: Centralb. fur Chir., 1S92, p. Gil. 



442 DISLOCATIONS. 

reappeared in the brachial and radial arteries; sensation and muscular 
function reappeared gradually. 

Of the cases that have been observed clinically the injury in most 
has been attributed to the reduction, as a consequence of too forcible 
traction, extreme abduction of the limb (arm), or to the presence of 
adhesions between the nerve and the parts with which it has been tem- 
porarily brought into contact. In some of these cases the correctness 
of this view cannot be questioned ; in others the necessary data for an 
opinion are lacking. 

A man l fifty-four years old was seized by the right arm and shaken 
so violently as to dislocate the humerus into the axilla, causing pain in 
the shoulder and instant loss of feeling and motion in the hand. 
Reduction on the third day. " Six weeks afterward the whole hand 
and lower side of the forearm were oedematous, and the former also 
hard and brawn-like, resisting pressure. The fingers were in the same 
state, and the whole hand was dark and congested, but not shiny or 
smooth. The joints from the wrist to the finger ends were sore, swol- 
len, and very stiff. The whole palm was the seat of pretty severe 
burning, with no darting or other pain." Partial loss of touch and 
pain-sense in the median and radial distribution. The elbow motions 
were perfect, wrist flexion good, extension lost ; flexion of the fingers 
good, extension and lateral motions lost from palsy of the extensors 
and interossei. 

A soldier 2 fell from a tree, striking upon and dislocating his left 
shoulder ; the dislocation was reduced within twenty-four hours, and, 
the previous pain and numbness disappearing, he remained well for 
four weeks, when the arm began to waste, with loss of power which 
became complete in a few months. Sensation was much less altered. 
At the close of a year there was only partial ability to flex the arm, 
and slight use of the flexors and extensors of the fingers. Marked 
atrophy ; contraction of the pronators. Rapid relief and final cure 
were obtained by electricity. 

A man 3 twenty-five years old was admitted to the Hotel-Dieu with 
an intracoracoid dislocation of the left shoulder, caused shortly before 
by a fall. Any motion communicated to the limb caused great pain 
and violent involuntary contraction of all its muscles. The next morn- 
ing the dislocation was found to have become subglenoid, the limb was 
completely paralyzed, but without loss of sensation, and although com- 
municated motion was still painful, it did not cause reflex contractions 
of the muscles. Reduction was readily effected with the aid of anaes- 
thesia. The muscles of the shoulder reacted to the faradic current; 
those of the arm and forearm did not. The limb wasted rapidly ; 
under electrical treatment an almost complete cure was obtained in 
about two years. 

Kronlein 4 quotes Hutchinson as having seen paralysis of the sciatic 
nerve follow an ischiatic dislocation of the femur ; and Sir Astley 
Cooper 5 quotes a case in which numbness of the limb accompanied the 

1 Weir Mitchell: Injuries of Nerves, p. 103. 2 Weir Mitchell: Loc. cit., p. 101. 

3 Duchenne: De l'Electrisation localisee, 2d ed., p. 179. 

4 Kronlein: Loc. cit., p. 34. 5 Cooper: Loc. cit., p. 67. 



COMPLICATIONS OF RECENT DISLOCATIONS. 443 

same injury. Cooper 1 also quotes a case of suprapubic dislocation in 
which the pressure of the head of the femur upon the anterior crural 
nerve caused numbness of the thigh. 

Viscera. Excluding the common implication of the spinal cord in 
dislocations of the vertebrae, there are few recorded cases of injury to 
parts lying within the body or neck by dislocated bones. Such injuries 
must, to a greater or less extent, accompany dislocation of the head of 
the femur through the floor of the acetabulum into the pelvis, and 
complete dislocation backward of the sternal end of the clavicle has 
in some cases been accompanied by symptoms indicating pressure on 
the trachea or oesophagus. 

A case that is entirely unique, and interesting not only because of 
the distance to which the bone was displaced, but also because of the 
changes subsequently undergone by the bone, and of the ease with 
which the deformity was borne, is reported by Prochaska 2 and by 
Larrey, 3 who had examined the specimen. A lad, sixteen or seven- 
teen years old, dislocated his right humerus by a fall upon the abducted 
elbow, and the head of the bone was driven between the second and 
third ribs (Prochaska says the third rib was fractured) into the chest, 
stripping up the pleura, but not perforating it. All attempts to reduce 
it were unavailing, and the subsequent treatment was limited to vene- 
section, warm baths, and antiphlogistic measures for the relief of urgent 
symptoms. The patient survived until the age of thirty-one (forty, 
Prochaska), and, although the arm remained abducted, gained his live- 
lihood by woodchopping. At the autopsy the head of the humerus 
was found within the thorax, covered by the pleura, and its neck firmly 
placed between the second and third ribs. The head was so soft that 
it yielded to the slightest pressure of the finger ; the articular cartilage 
and bony texture of all the portion that lay within the chest had 
entirely disappeared, leaving only a few membranous remains of the 
humerus, of which the greater part seemed to belong to the costal 
pleura. Prochaska describes it as " naked, soft, yielding to the softest 
pressure, presenting only a thin envelope, and almost empty within, 
since it had lost more than half of its internal bony substance." 

Soft Parts and Integument (Compound Dislocations). Although 
instances of this complication have been recorded for almost every 
joint, they are yet of rare occurrence, and mainly restricted to the 
elbow, knee, ankle, and phalanges. Except in the latter case, they 
are commonly the result of extreme violence, and the wound of the 
skin is produced either by the direct action of this violence, or from 
within outward by the projecting end of the bone. 

The complication in the case of the larger joints is very grave. 
because of the extent of the injury, which is usually great and marked 
by much laceration and bruising of the tissues, and also because of the 
special dangers due to the probable infection of the wound. 

The treatment may require, in addition to the most rigorous anti- 
septic measures, the partial excision of the joint, because o\' the diffi- 

1 Cooper : Loc. cit., p. 74. 

2 Prochaska : Disquisite Anatomico-physiol. Org-. Humani. Wien, 1812, quoted by 
Malgaigne. 

8 Larrey: M6m. de Chir. Militaire, vol. ii. pp. 405-407. 



444 DISLOCATIONS 

culty of otherwise providing efficient drainage of all the recesses and 
pouches of the synovial sac. 

Compound dislocations of the shoulder and hip are rare, those of the 
elbow and knee less so, and those of the smaller joints much more 
frequent. 

REPAIR. 

Only a few observations have been made of reduced dislocations 
undergoing, or that have undergone, repair. Clinically it is known 
that after a period of a few days or weeks marked by gradually 
diminishing tenderness and swelling, the joint can be freely used with- 
out pain, but that sometimes the range of motion remains limited for 
a much longer period, and that in some cases there is a marked ten- 
dency to recurrence of the dislocation. In a few cases, in which 
patients have died within a few days after having suffered a disloca- 
tion, the surrounding tissues have shown the remains of the extrava- 
sation of blood that had taken place amid them, and the rent in the 
capsule has either been occupied by a clot or has been empty and 
without evidence of repair. It is to be presumed, however, that repair 
usually takes place after dislocation, as after other subcutaneous injuries, 
without suppuration or even much inflammatory reaction, that the 
ruptured capsule reunites or that the gap in it is filled by condensation 
and adhesion of the adjoining connective tissue, that the lacerated 
muscles and ligaments are repaired in like manner, and that these 
cicatrices pursue the evolution common to their class. 

This process may, however, be disturbed by various complications. 
If the injury has been exceptionally severe, if the bone has been widely 
displaced, and the surrounding tissues much lacerated, if the efforts to 
reduce have been violent and long continued, if the joint has not been 
properly immobilized, if passive motion has been injudiciously begun 
and maintained, or, finally, if the general condition of the patient is 
unfavorable for repair, the inflammatory reaction may become exces- 
sive, and even end in suppuration and pyaemia. If it stops short of 
this disastrous result, it may yet lead to partial or complete anchylosis 
through the formation of adhesions between the opposed articular sur- 
faces or the thickening and retraction of the capsule and peri-articular 
tissues. The older records contain numerous instances in which sup- 
puration appears to have been caused by the efforts to reduce, but this 
accident has become much less common since the introduction of anaes- 
thesia and the substitution of the so-called " mild " methods by manip- 
ulation for the forcible traction by pulleys which was formerly so much 
in vogue. 

Fractures of apophyses, or portions of bone to which muscles or liga- 
ments are attached, are repaired either by bony callus or by a fibrous 
band, the difference depending on the extent of the separation and the 
independent motion of the fragment. The fragment may be withdrawn 
to such a distance that the attached muscle or muscles permanently 
cease to exercise any control over the main bone, which, in conse- 
quence, is exposed to frequent and easy recurrence of the dislocation. 

The same infirmity may result from defective repair of fracture of 



REPAIR OF RECENT DISLOCATIONS. 



445 



Fig. 259. 



the rim of ;m orbicular cavity. Instances of the former variety are 
most common at the shoulder-joint, those of the latter are found at the 
hip and shoulder. Another cause of the liability to recurrence at the 
shoulder — laxity of the capsule — has been indicated by Jossel, 1 who 
had the opportunity to examine four such cases after death ; he found 
in all that the supraspinatus and infraspinatus muscles had been torn 
loose from their attachment to the greater tuberosity, had retracted 
behind the acromion, and had un- 
dergone atrophy and fatty degenera- 
tion. The relations of the tendons 
of these muscles with the articular 
capsule are so close that the rupture 
of the former involves also that of 
the latter, and the retraction of the 
former creates, by drawing back one 
side of the rent, a large gap in the 
upper part of the capsule opening 
into the subacromial bursa. In the 
process of cicatrization the front part 
of the capsule, that lying between 
its attachment to the humerus and 
the rent, becomes adherent at the 
edge of the rent to the under sur- 
face of the deltoid close by its at- 
tachment to the acromion, while the 
posterior lip of the rent, after retrac- 
tion with the tendon, becomes per- 
manently fixed at the posterior part 
of the acromion. The under surface 
of the acromion is thus left to fill 
the gap between the two lips, to 
form the upper limit of the articular cavity, and to be in direct con- 
tact with the head of the humerus. In none of Jossel's four cases 
was the normal communication between the cavity of the joint and 
the subscapular bursa found to be enlarged ; in one the subcoracoid 
bursa communicated with the joint, and in one the tendon of the 
long head of the biceps was ruptured, and its torn end had become 
fixed in the bicipital groove. In two of the cases a small defect with 
smooth edges was found in the capsule below the tendon of the sub- 
scapulars, and in the others the capsule appeared thinned at the same 
point. Apparently this indicated the place at which the head of the 
humerus escaped through the capsule at the time of the first dislo- 
cation. 

The cavity of the joint was greatly enlarged by the changes in the 
capsule; in the first its capacity was 90 cubic centimetres, as against 
28 in a normal joint, and its length along the upper portion was 10 
centimetres instead of the normal 3}. 

This condition of the capsule, aided by the withdrawal oi' the con- 
trol and support normally supplied by the supraspinatus and infra- 

1 .Kissel : Deutsche Zeitschrift fur Chirurgie, 1880, vol. xiii. p. it;?. 




Recurrent or habitual dislocation of the 
shoulder, showing the opening into the sub- 
acromial bursa. (Jossel.) 



446 DISLOCATIONS. 

spinatus, muscles, seems entirely adequate to explain the easy recur- 
rence of the dislocation, and the recent cases of relief by operative 
shortening of the anterior portion of the capsule are corroborative of 
the opinion. 

Gangrene of the limb may ensue upon the rupture of the principal 
vessels, or even upon extensive laceration and violent inflammatory 
reaction ; and paralysis of one or several muscles may manifest itself 
immediately or only after the limb is again brought into use, the result 
of injury to nerve trunks or of contusion of the muscle itself, or of 
compression of the nerve by a cicatricial band as in 
quoted above, p. 441. 



CHAPTER XXX. 

THE PATHOLOGY OF UNREDUCED ("ANCIENT," "INVETERATE") 

DISLOCATIONS. 

The changes that take place about joints that have long remained 
dislocated are well understood, through direct observations of many 
specimens in man and through experiment upon animals. These 
changes are partly the direct result of purely inflammatory processes 
excited by the traumatism and the changed relations of the parts, 
partly that of disease, and partly that of a seeming effort of nature to 
create a new and serviceable joint. The changes consist, in general 
terms, in the condensation and thickening of connective tissue about 
the displaced bone in such a manner as to protect it against further 
displacement, and in the change of the bones at the new points of con- 
tact partly by absorption and partly by the formation of new bony 
outgrowths through continued slight irritation of the bone itself, the 
periosteum, and the adjoining fibrous and ligamental tissues. The 
irritation which leads to these changes is furnished by motion, use, of 
the limbs ; the most striking examples are found at the shoulder and 
the hip, and these will be used as the basis of the following description. 

The first changes, in point of time, are those in the bruised and torn 
soft parts amid which the end of the bone has lodged after its escape 
through the rent in the capsule. The loose connective tissue lying 
about the vessels, nerves, and muscular bundles, bruised and pressed 
back by the head of the bone and infiltrated with extravasated blood, 
reacts in the usual manner under the traumatism by becoming the seat 
of an exudation and by multiplication of its cellular elements. The 
latter follow their natural evolution into fibrous tissue, and thus is 
formed about the bone a continuous fibrous envelope enclosing a cavity 
within which the end of the bone lies, more or less free, and continuous 
structurally on its outside with the adjoining tissues, some of which — 
vessels, nerves, and muscular fibres — may be firmly imbedded in it. 
Its inner surface is smooth and lined with flat cells resembling those 
found on the surface of normal or accidental bursa 1 , and it is moistened 
by a small amount of liquid which, in some cases, closely resembles 
synovia. It seems probable that when real synovia is present it is 
furnished by portions of the original capsule which have remained 
adherent to the bone and have formed part of the new cavity. Indeed, 
the new cavity is usually only an enlargement of, or addition to, the 
original one, its connection with, or its entire independence of, the old 
one being determined by the character and extent of the rent in the 
capsule and the distance to which the head o\' the bone has passed 
through it ; but the capsule may be torn away from the humerus, tor 
example, so completely that it falls together behind it and its cavity is 

447 



448 



DISLOCATIONS. 



obliterated by adhesion of the opposing surfaces or is shut off by union 
of the torn edges. The new capsule is so small and close and the 
bands formed between the bones by the condensation and increase of 
the surrounding tissues are so firm that motion is greatly restricted or 
wholly lost, and restoration of the original relations can be effected only 
after a division or laceration of those tissues far more extensive than 
that which accompanied the dislocation. 

But while these changes in the soft parts tend permanently to fix the 
bone in its new position, other changes take place in the periosteum 
and the bone itself upon which the displaced articular end rests and 
moves, which, on the other hand, tend to make this new position a 



Fig. 260. 



Fig. 261. 





Old supracotyloid dislocation of the femur, with 
very complete new acetabulum. From the collec- 
tion at Bonn. (Kronleix.) 



Scapula showing new socket found in 
an old unreduced subcoracoid disloca 
tion. (Cooper.) 



more suitable resting-place and to give it a form and character like 
those of the part it is to replace. Thus, a new cotyloid cavity may be 
formed upon the ilium, or a new glenoid cavity on the inner side of 
the scapula adjoining the old one. In this new formation of bone two 
processes may take part — production of bone by the periosteum, and 
ossification of the old ligaments and new fibrous tissue. The perios- 
teum may produce bone either after it has been stripped up or while it 
is still in place. If, in the dislocation of the head of the bone, a por- 
tion of the rim of the corresponding articular cavity is broken off and 
pushed away, carrying with it a strip of periosteum torn from the 
adjoining surface, but preserving its connection with both pieces, or if 
the periosteum is stripped up by the attached capsule or a ligament, as 



PATHOLOGY OF UNREDUCED DISLOCATIONS. 



449 



occurs so frequently at the elbow, this loosened strip forms on its side 
the limit of the new cavity, and produces on its under surface new 
bone which is continuous with the old and with the fragment of the 
rim, if such has been broken off, constituting a bridge between them. 

If the periosteum is not stripped up, but the head of the bone escapes 
entirely from the cavity and comes to rest upon the outside of a layer 
of periosteum still adherent to its bone, this periosteum, irritated by 
the pressure and movements, produces new bone between itself and the 
old, and this production is greatest in the zone just around the point of 
greatest pressure. The portion of periosteum directly pressed upon dis- 
appears under the pressure, leaving a bare surface of bone in contact 
with the displaced head, or becomes fibrous or fibro-cartilaginous in 
structure ; while in the immediately adjoining portion the osteogenetic 
property is called into play and a ridge of bone is built up around the 



Fig. 262. 




Backward dislocation of elbow. Bony fusion between ulna and humerus. 

central denuded area. This may be a sharply defined rim rising to a 
considerable height and closely resembling that for which it is a sub- 
stitute, or it may be a mass of irregular height and outline, having little 
or no resemblance to either the glenoid or cotyloid cavity. 

The details of this formation, as observed by Baiardi * at the hip in 
animals, consist, first, in the appearance of a circular cartilaginous wall 
whose free border is continuous with the new-formed fibrous capsule, 
its base resting upon the ilium and its inner surface in contact with the 
head of the femur; its ossification (in rabbits) is complete by the thir- 
tieth day, except along its concave surface, where it remains soft. 
shading off toward the centre of the new acetabulum into a whitish, 
cartilaginous like tissue, which takes the place of the destroyed perios- 
teum. On its free border it has the structure of fibro-cartilage ; on the 
concave surface it closely approximates that of hyaline articular car- 
1 Baiardi: Arch, per le Scieuze mediehe, 1880, vol. iv., quoted by ECrdulein. 



450 DISLOCA TIONS. 

tilage. At the very centre the underlying bone is left bare or is 
covered by fibrous tissue and fibro-cartilage, and becomes denser in 
structure. Grinewetsky, 1 who experimented on dogs, says he never 
found a lining of periosteum or cartilage inside the new acetabulum ; 
the bone was always sclerosed. He also notes the absence of endothe- 
lium on the inner surface of the new capsule. 

The ossification may pass beyond the usual limits and include por- 
tions of the capsule, 2 forming bony stalactites, or even a complete 
bony case enveloping, and perhaps united with, the head of the bone; s 
and in a specimen presented by Moreau, 4 a dislocation of the femur 
into the obturator foramen, the membrane filling the foramen had been 
transformed into a bony plate throughout, except in a strip along its 
anterior margin. 

Some of these experimental observations have been repeated upon 
specimens of ancient dislocations in man, in some of which the new 
cavity has been found to be lined with fibro-cartilage, 5 in others 
with a granular fibroid tissue without apparent cartilage of incrus- 
tation. 6 

The displaced head shows changes varying in extent and consisting 
in loss of its cartilage, erosion of the bone in places and its increase in 
others, and occasionally in profound changes of structure throughout. 
Thus in the case just referred to, reported by Duguet, a dislocation 
inward of the shoulder of six months' standing, the head of the 
humerus was worn away behind at the point where it rested against 
the rim of the glenoid cavity, which also had in great part disappeared ; 
its anterior portion had preserved its cartilage at almost all points, 
while its posterior portion had none, it being there replaced by rather 
tight, short fibrous bands uniting the head to the old glenoid cavity. 
In a specimen presented by Walsh 7 to the Royal Surgical Society of 
Ireland, April 25, 1840, of an old dislocation of the shoulder forward, 
the subscapulars muscle was raised from the scapula by the head of 
the humerus, the new glenoid cavity was covered by fibro-cartilage, 
the synovial sac was complete, and the cartilage of the humerus perfect. 
Old backward dislocations of the elbow (q. v.) often show a very com- 
plete new radio-humeral joint. 

The empty glenoid or cotyloid cavity diminishes gradually in size 
either by absorption of that portion against which the head of the bone 
rests or by a general atrophy, presumably due to its disuse, similar to 
that observed in the alveolar process after removal of the teeth, and 
its cavity fills up with fibrous tissue that springs from and replaces its 
lining cartilage. The glenoid cavity has in some cases been still further 
rendered unfit for use and inaccessible by union with the outer portion 
of the original capsule, when that has been drawn across its face as the 
humerus was displaced inward. And yet, occasionally the acetabulum 

1 Grinewetsky: Centralblatt fur Chirurgie, 1839, p. 279. 

2 Thore : Bull, de la Soc. Anatomique, 1839, p. 33. 

3 Cooper: Loc. cit., p. 50; and Cruveilhier : Anat. pathol., vol. i. p. 425. 
* Moreau : Mem. de l'Acad. royale de Chirurgie, 1769, vol. ii. p. 153. 

5 Lepine and Desorrneaux : Bull, de la Soc. Anat., 1844, p. 167. 

6 Duguet : Bull, de la Soc. Anat., 1863. j.. 144. 

7 Walsh : Gazette des Hopitaux, 1840, p. 330. 



PATHOLOGY OF UNREDUCED FRACTURES, \->\ 

has remained empty, and its cartilage unchanged for many years (JJreli- 
mann). 1 

When the use made of the limb is very slight and the head of the 
bone is immovably fixed in its new position, the development of artic- 
ular characteristics is slighter and the bone may even diminish nota- 
bly in size or consistency, as in the case quoted on page 421, in 
which the head of the humerus passed into the chest and remained 
fixed there. This atrophy of disused parts is a general rule, and 
although observed in bone is more marked in other tissues whose nutri- 
tive changes and functional activity are greater. In accordance with 
this general law the muscles which are rendered inactive by the greater 
or less fixation of the dislocated bone diminish in size, and if their 
inactivity is complete, or even nearly so, their fibres undergo an actual 
degeneration and their fibrous tissue predominates to such an extent 
that they are hardly more than ligaments. The bone, too, is similarly 
affected throughout its entire length ; it becomes smaller, or, if the 
dislocation has occurred during youth, before development is complete, 
it fails to develop to the same extent as its fellow on the opposite side, 
and even its normal curves disappear. 

These facts show both the danger and the futility of attempts to 
reduce dislocations that have long existed ; they show that reduction 
can be accomplished only at the cost of lacerations far more extensive 
than those involved in the original injury, that among these lacera- 
tions may be included rupture of important vessels or nerves that have 
become adherent to or included in the fibrous bands of new formation, 
and that even if the bone can be successfully liberated from its attach- 
ments and brought back to the cavity from which it was displaced the 
latter may have become entirely unfit for its reception and for a resump- 
tion of its own original functions. 

Important changes in the condition of the limb may be caused by 
pressure upon the bloodvessels or nerves by the displaced bone or by 
injury done them during attempts at reduction. Instances of the latter 
are given in Chapter XXXIV. 

Persistent oedema, resulting in a condition resembling elephantiasis, 
was observed by Bartels 2 in a patient whose shoulder had been dislo- 
cated for more than a year. There was also rigidity of the fingers in 
a position indicating ulnar paralysis, which was relieved by increasing 
the mobility of the shoulder, but the oedema persisted. 

1 Drehrnanu : Beitrage zur klin. Chir., 1897, vol. xvii. 

2 Bartels: Arch, fur klin. Chir., 1874, vol. xvi. p. 638. 



CHAPTEK XXXI. 



SYMPTOMS AND DIAGNOSIS. 



The symptoms'of a dislocation — those changes in the form, functions, 
and sensibility of the part by which the presence of a dislocation is recog- 
nized — are classed as objective and subjective or rational. The former, 
which alone are deemed demonstrative, are those which can be recog- 
nized by the surgeon on examination ; the latter are those for his knowl- 
edge of which he must depend, to a greater or less extent, upon the 
statements of the patient. 

The examination of the patient should always be conducted sys- 
tematically, with the view to learn not merely the existence of the 
dislocation, but also such details and complications as may be present 
and may affect the treatment and prognosis ; and it should include an 
examination of the condition of such bloodvessels and nerves as may 
have been injured at the same time, in order that such injuries, if their 
later consequences should become manifest, may not be attributed to 
the treatment. If swelling, a large amount of subcutaneous fat, or 
pain should prevent a satisfactory examination, anaesthesia should be 
employed. The character and direction of the force that produced the 
dislocation should be learned, and also, if possible, the position of the 
limb at the moment of its dislocation, and whether a "consecutive" 
has been substituted for a " primary " displacement, or, as evidence of 
the latter fact, whether one fixed position of the limb has been sub- 
stituted for another. In doubtful cases the uninjured limb should be 
used for comparison, and the question should be asked whether or not 
the suspected joint has been previously the seat of disease or injury the 
consequences of which may affect the conclusions to be drawn from 
the examination. The essential point in the examination is to deter- 
mine the position of the end of the bone, its relations to that one from 
which it is thought to have been violently separated, and the best 
evidence of this fact is furnished by feeling the end of the bone with 
the fingers, by tracing its outline, by feeling it move when the lower 
part of the limb is moved. 

Objective Signs. 

Deformity. Beside the attitude of the patient or of the limb, which 
is often strikingly characteristic, the aspect of the region of the affected 
joint is changed by the inflammatory swelling, which may appear 
promptly or tardily and be accompanied by ecchymosis and by altera- 
tions in the depth or position of the fold of its flexure and in its normal 
depressions and prominences. The swelling varies with the length of 
452 



SYMPTOMS AND DIAGNOSIS. 453 

time that lias elapsed since the injury was received, increasing for a day 
or two, remaining stationary for a variable time, and then diminishing ; 
in old cases the region is atrophied. If the dislocation has been caused 
by external violence acting directly upon the region of the joint, the 
swelling is increased by the eifects of the contusion, and ecchymoses 
appear more promptly than in other cases. 

The position, with reference to each other, of the articular surfaces 
or ends which constitute the joint can often be determined by palpation, 
and this furnishes the most exact and positive evidence of the character 
of the injury. In joints that are not thickly overlain by soft parts or 
masked by swelling or extravasated blood, this position can be readily 
made out, as at the knee, lingers, elbow, or even the shoulder ; at the 
hip it is easy in some dislocations — e. g., suprapubic — to recognize the 
head of the femur, in others it is much more difficult. 

If the head of the bone cannot be felt, its position (if there is no 
fracture) can be determined from that of its shaft and recognizable 
prominences or apophyses. Thus, if the great trochanter can be recog- 
nized, the position of the head of the femur can be readily inferred by 

Fig. 263. Fig. 264. 





Diagram to show the effect of position upon the appar- Diagram to show the action of a liga- 
ent length of the arm in dislocation of the shoulder. A, mcnt in limiting the range of motion 
acromion ; B, lower end of humerus ; C, head of humerus, in a dislocation. 

prolonging from it in imagination the neck of the femur in the line 
indicated by the position of the shaft. In like manner prolongation 
upward of the line of the lower portion of the humerus indicates the 
position of the head of the bone, and if it passes to the inner side of 
the acromion the shoulder must be dislocated or the bone broken. 

The continuity of the supposed head with the shaft is determined by 
recognizing that it participates in slight movements communicated to 
the lower segment of the limb. By prolonged firm pressure with the 
fingers an inflammatory swelling may sometimes be pushed aside and 
the bone distinctly felt. 

The limb may appear to be, or may actually be, shortened or length- 
ened, but this sign is not of so much value as it is in cases of fracture, 
both because it varies greatly with varying positions of the limbs and 
because the limbs cannot always be placed symmetrically. The reason 
why the length of the measured distance varies in different positions 
of the limb can be made clear by taking an example, as the shoulder. 



454 DISL OCA TIONS. 

Here the distance usually measured is that from the edge of the acro- 
mion to the external epicondyle of the humerus. Now, this distance 
diminishes as the arm is abducted, for (Fig. 263) when the arm hangs 
by the side, the line A B is almost exactly equal to C B plus the dis- 
tance that C lies below the level of A; while, on the other hand, when 
the arm is abducted the distance .4 B' is equal to C B minus the dis- 
tance of C beyond the line of ^4. 

The methods of measuring and the precautions to be taken are the 
same as in the case of fracture and have been elsewhere considered ; and 
the possibility of the previous existence of asymmetry of the limbs, of a 
difference in their length, has also been described. (Fractures, p. 51.) 

Loss of Mobility. In almost every dislocation there is a position 
which is characteristic of it and which the limb tends spontaneously 
to assume and retain, even under anaesthesia. This position depends 
rather upon the tenseness of ligaments and untorn portions of the cap- 
sule than upon the muscles, although the latter by being already over- 
stretched may aid in limiting motion or change of position in certain 
directions. The head of the bone takes up a new position at some 
distance from its normal one and there establishes a new centre of 
motion for the limb ; consequently the ligaments on the side opposite 
that toward which the head has been displaced are put upon the stretch 
if the attempt is made to move the lower part of the bone in the 
same direction, and, unless torn, fix it at an angle with the other 
bone to which they are attached (Fig. 264). The bone can be moved 
toward the attachment of the untorn ligament but not further away 
from it. 

Since the limitation of motion has its principal cause in the non- 
muscular structures, it cannot be entirely removed by anaesthesia, but 
such additional limitation as may be due to contraction of the muscles 
excited by the fear of pain can be thus removed, and whenever the 
fixity of a limb is used as an element in making the diagnosis the part 
taken by the muscles in its production should be determined. The 
diagnostic formula sometimes given that abnormal fixation is charac- 
teristic of dislocations, and abnormal mobility of fractures, is a partial 
statement that may be misleading, for in fracture, or even in contusion, 
near a joint complete fixation may be effected by the muscles, and in 
dislocation with extensive laceration of the capsule and ligaments the 
range of motion may be very wide, and in all it is generally free in 
some direction. 

A therapeutical fact that may often be of importance is to be deduced 
from the fact that the dislocation must, in most cases, have taken place 
when the limb was in one of the positions in which, while still dislo- 
cated, it is shortened — that is, one in which the distance from its normal 
opposing articular surface to its lower end is less than that between the 
corresponding points of the opposite limb in a similar position ; by 
replacing the limb in the position it occupied when the dislocation took 
place the first step in reduction, that of bringing the head of the bone 
opposite the rent in the capsule through which it has escaped and relax- 
ing the soft parts, is taken. 



SYMPTOMS AND DIAGNOSIS. \->~> 

Crepitus. A sound or sensation .somewhat resembling the crepitus of 
a fracture is occasionally perceived while a dislocated limb is being 
handled. It may he the real crepitus of a" fracture accompanying 
the dislocation, or merely the grating of the head of the hone against 
the edge of the periosteum of the other, or against a fibrous band, or 
even (it is said) against a blood-clot. 

Subjective Symptoms. 

Pain. The occurrence of the dislocation is immediately followed by 
sharp pain in the region of the joint, which may gradually diminish or 
may continue for some time with unabated severity. In the former case 
it is presumably due in great part to the laceration and bruising of the 
tissues ; in the latter to the tension of those parts that have not yielded 
to the strain. In the former case the pain is not materially relieved 
by reduction ; in the latter it immediately disappears when the bone is 
restored to its place. In addition to this pain about the joint, there 
may also be tingling or numbness through the limb in consequence of 
pressure upon the large nerve trunks. 

Loss of Function. Inability to use the limb is ordinarily complete, 
and is due partly to the fixation created by the changed relations of the 
bones and partly to the pain which movement causes. There is noth- 
ing characteristic in this symptom, since it is present also after fracture 
and even after a severe contusion. Furthermore, it is sometimes absent, 
or present in so slight a degree that the patient continues to use the 
limb, conscious only of some slight pain and of a certain inconve- 
nience or lack of freedom in its use. 

History. The history of the case includes the character of the vio- 
lence, the position of the limb at the moment of the accident, possibly 
the perception by the patient at that moment of a sound, of the sensa- 
tion of displacement, and the history of any previous injury to or dis- 
ease of the part or of the opposite limb so far as it may affect its use 
for the purpose of comparison. It is well to obtain this history before 
proceeding to the direct examination of the limb. 

There can be no uncertainty as to the main fact if the relations to 
each other of the articular ends can be made out, and the surgeon 
should not rest content with less than this when it can possibly be 
attained. In every doubtful case an anaesthetic should be employed, 
and among the doubtful cases are those in which there is the possible 
coexistence of a fracture either of a portion of the articular surface or 
of the entire breadth of the bone near the joint. The latter form of 
fracture is itself the one with which a dislocation is most frequently 
confounded ; either may be mistaken for the other ; and in any such 
case, every effort should be made to determine the exact positions occu- 
pied by the ends of the bones. 

In dislocations complicated by fracture of portions oi % the articular 
surface or of tuberosities to which muscles are attached, the coexistence 
of the fracture is often incapable of demonstration and can only be 
suspected because of the facility with which the dislocation recurs after 
reduction. 



456 DISLOCATIOXS. 

Such complications as injury of a main bloodvessel or nerve will be 
readily recognized by attention to the characteristic symptoms to which 
they give rise. 

Finally, it should be remembered that the most experienced and care- 
ful surgeons have sometimes remained in doubt, or have denied the 
existence of a dislocation which the subsequent course of the case has 
shown to have been present, and the charity which the critic may him- 
self so soon need should be cordially extended to others. 



CHAPTEK XXXII. 



COURSE AND PROGNOSIS. 



If the dislocation is promptly reduced and no complications are 
present, the course is simple and the prognosis favorable. The swell- 
ing and pain subside, and the patient is soon able again to use the limb, 
although usually with some limitation of the range of motion and with 
pain when these limits are reached. This slight disability may persist 
for weeks, or even months, especially in those who are constitutionally 
prone to arthritic complications. I have known a robust, thoroughly 
healthy man to dislocate his shoulder, the dislocation being so slight 
that it was immediately reduced by accidental traction on the arm and 
he was able to use the limb without a day's intermission ; and yet, 
three months after the accident he was unable to lift the elbow in 
abduction to the level of the shoulder, and could not carry his hand to 
his hip-pocket without causing considerable pain. 

If the inflammatory reaction is more severe, the pain and swelling 
are greater and more prolonged, and the limitation of movement may 
become permanent through the formation of adhesions or the conden- 
sation and thickening of the peri-articular soft parts. It is very excep- 
tional for this process to go on to suppuration. 

If the disarticulation is compound, it may follow either one of two 
courses ; either it is transformed into a simple one by the prompt union 
of the wound, or suppuration ensues and the patient is exposed to all 
the accidents of a deep suppurating wound, rendered all the more exten- 
sive by its continuity with the interior of the joint. In the latter case 
the result is certain to be marked by much functional disability, per- 
haps by total loss of mobility in the joint. 

Other complications add to the otherwise uneventful course of a 
simple dislocation the features peculiar to themselves; thus, injury to 
a nerve may be followed by temporary or permanent paralysis of the 
muscles or loss of sensation in the region supplied by it, or by a long 
train of symptoms indicating an ascending neuritis. And injury to a 
main artery may be followed by gangrene of the limb, or by the forma- 
tion of a traumatic or encysted aneurism. The coexistence of a fracture 
of the neck of the bone creates a condition which for a time predomi- 
nates over the dislocation ; if the latter is promptly reduced the case 
follows essentially the course of a fracture ; if it cannot be at once 
reduced the course at first is still in the main that of a fracture, and 
subsequently that of an old dislocation. 

The fracture of a portion of the articular edge, or of an apophysis, 
is habitually followed by no symptoms peculiar to itself, except in some 
cases a marked tendency to recurrence of the dislocation after its reduc- 
tion, and this tendency may persist throughout life. 

Excluding these complications, the prognosis in a simple dislocation 

457 



458 DISLOCATIONS. 

of a limb, quoad vitdm, is eminently favorable ; the prognosis with 
regard to the restoration of form and functions depends upon the 
redncibleness of the dislocation, and this is affected by the character 
of the joint and of the injury, by complications, and by the time that 
has elapsed since the injury was received. 

The principal obstacle to the reduction of a dislocation commonly 
lies in the tension of the nntorn portion of the capsule and ligaments, 
but special difficulties may arise from the relations of the displaced 
bone to the capsule and to various muscles and tendons. The capsule 
may slip in between the head of the bone and the cavity it has left, 
and create an obstacle (by its interposition) that cannot be removed by 
manipulation or traction of the limb, or its torn edge may be drawn 
tightly about the neck of the bone, as is common at the metacarpo- 
phalangeal joint. The cases in which the former happens are those 
in which the capsule is freely torn at or near its attachment to the 
humerus or femur, and in which the head of the bone is displaced 
entirely to the outside of the capsule. 

The greater the length of time since the occurrence of the disloca- 
tion, the greater will be the difficulty of reduction ; and after the lapse 
of a certain length of time, which is different in different cases, reduc- 
tion becomes impossible. The cause of this difficulty has been 
described in Chapter XXX. 

The period at which a dislocation is to be deemed unfit for reduc- 
tion cannot be positively stated ; it varies with different joints and 
different cases. Speaking generally, it is about two months for the 
larger joints, but it is not prudent to assume that any dislocation which 
has remained unreduced for a shorter period than two months is re- 
ducible, or that every one that is older is, therefore, irreducible ; for in 
the former case we may be led to apply an amount of force that will 
prove disastrous and in the latter disabilities that are amenable to 
treatment may be left unrelieved. A better guide is to be found in 
an examination directed to ascertaining the changes produced in the 
parts by the original injury or the disuse, and in careful, judicious 
attempts to make reduction. The object of these attempts should not 
be to reduce the dislocation at any cost, but to reduce it only if the 
reduction can be accomplished by moderate force and without grave 
lacerations. And, indeed, I am convinced that in a doubtful case it is 
better to expose the bone by incision, and divide the obstructing tissues 
with the knife, rather than blindly to rupture them by the application 
of a force whose action cannot be intelligently directed, and whose 
effects cannot be certainly foreseen and controlled. That the warning 
is still needed is shown by the recent (1897) death of a patient in the 
Xew York Hospital after an attempt to reduce a dislocation of the 
shoulder of six weeks' standing by traction and manipulation which 
ruptured the axillary vein and broke the third, fourth, and fifth ribs. 

Encouragement to attempt reduction even when the dislocation has 
remained unreduced for a period much longer than that of two months 
above mentioned is furnished by not a few recorded cases in which it 
has been completely successful; .instances will be given in the follow- 
ing chapter. 



CHAPTER XXXIII. 

TREATMENT. 

Spontaneous Reduction — Obstacles to Reduction — Anaesthesia — Methods of 
Reduction — Old Dislocations — After-treatment — Habitual Dislocation. 

As a rule, to which there can be very few except ions, reduction of 
a dislocation should be attempted at the earliest opportunit}^ The 
possible exceptions are cases in which the inflammatory reaction is 
already very great, and in which it may be anticipated that the addi- 
tional violence inflicted during reduction would dangerously increase 
it. But even in such cases it would be well to make gentle efforts to 
reduce under ether, and to postpone the reduction only if these efforts 
proved unavailing. 

Spontaneous reduction is the term applied to that which takes place 
without the intentional intervention of any external force. It may 
take place while the patient is asleep, through the action of the 
attached muscles or through some chance violence, or by a fall or a 
sudden movement. 

Spontaneous reduction, without the aid of external force, has fol- 
lowed shortly after attempts to reduce which have been unsuccessful 
but which may be thought to have made spontaneous reduction pos- 
sible by rupture of adhesions, or laceration of the tissues, or fatigue 
of the muscles. This variety was termed consecutive reduction by 
Leveille, and the term was adopted by Malgaigne, who applied it both 
to cases in which spontaneous reduction takes place after complete 
failure of the efforts to reduce and also to those in which an incom- 
plete reduction spontaneously becomes complete or is gradually made 
complete by prolonged action of some force applied by the surgeon — 
such as pressure. 

The obstacles to the reduction of recent uncomplicated dislocations 
arise from inflammatory swelling of the soft parts, muscular contrac- 
tion excited by pain or the fear of pain, the inextensibility of untorn 
portions of the capsule or ligaments of the joints, the interposition of 
portions of the capsule between the head of the bone and its cavity, 
and the size and position of the rent in the capsule. Not all of these 
are present in every case, and they vary in importance. For a long 
time the muscles were deemed the most important, but observations 
and experiments upon the cadaver carried on at about the same time 
by several different persons — Gunn 1 in 1851, Gelle" and Bigelow 3 in 
1861, Streubel 4 in 1862, and Busch 5 in 1863— fixed the attention of 

1 Gunn : Peninsular Journal of Medicine, July, 1855, p. 27. 
* 2 Gelle : Archives g«?nerales de Med., April and May, 1861. 
3 Bigelow : The Hip. 

* Streubel: Vierterjahreschrift fur prakt. Heilkundo. 1862, vol. ii. p. 59. 
5 Busch : Arch, fur klin. Chirurgie, 18(5:?, p. 1. 

459 



-460 DISLOCATIONS. 

surgeons upon the relations between the bone and the capsule, showed 
the nature and importance of the opposition commonly offered by the lat- 
ter, and established the basis of treatment by systematic manipulation. 
An account has already been given of the part played by the untorn 
portion of the capsule in determining the position assumed by the limb, 
a part so important that in " regular " dislocations (the term given by 
Bigelow to those in which the rent in the capsule is only partial and 
occupies a certain definite place in it) the muscles surrounding the 
joint may all be divided without thereby modifying the position of 
the limb or increasing its range of motion. At the hip the portion 
which remains untorn in all the typical forms is the anterior portion 
or Y-ligament ; at the shoulder it is the thicker anterior portion form- 
ing the so-called coraco-humeral ligament. It is more correct to speak 
of the obstacle offered to reduction by this untorn portion of the cap- 
sule as an obstacle not to reduction in general, but only to reduction 
by certain methods, for Avhen properly managed it offers no opposition, 

and may possibly even be of assistance. It 
Fig. 265. may be compared to the link of a sleeve- 

button, which in some positions absolutely 
prevents the button from passing back 
through the button-hole, while in other 
positions the passage is easy. Thus, if the 
head of the bone is lodged behind a pro- 
jecting portion of the rim of the articula- 
tion, the ligament (Fig. 265) is tense, and 
traction in any direction which tends to 
separate its points of attachment is effectu- 
ally opposed by it ; but if these points are 
brought nearer together by moving the 

Diagram to illustrate the action ghaft f ^ honQ {n the dire * ction indicated 

of an untorn ligament or portion . , it • i i 

of capsule in opposing reduction. by the arrow, the ligament is thereby re- 
laxed and its opposition to the movement 
of the head of the bone toward its cavity annulled. The position of 
the untorn portion of the capsule or ligament must be inferred from 
the posture of the limb and the directions in which motion is strongly 
opposed. 

In "irregular" dislocations, those in which a characteristic attitude 
is not taken by the limb and in which the mobility is marked, these 
differences are due to extensive rupture of the capsule ; and this, by 
removing the restraint imposed in other cases by the untorn portion 
of the capsule, makes reduction remarkably easy without much atten- 
tion to the position in which the limb is held during the attempt. 

In addition to this opposition to movement or traction in certain 
directions, the capsule may offer other obstacles arising from the form 
and position of its rent and from its own interposition between the head 
of the bone and the cavity in which the latter is to be replaced. The 
tearing of the capsule is caused by the pressure of the head upon it, 
consequently the rent is on the side toward which the head is displaced, 
and it may be longitudinal or transverse at either attachment, or present 
a combination of the two forms. In order that either of these obstacles 




TREATMENT. 401 

should be present, it is necessary that the head of the bone should have 
passed entirely through the rent — that, in other words, its displacement 
should be marked. As the rent, under these circumstances, is large 
enough to allow the head to pass out through it, it is large enough 
to allow it to be brought back through it if it is not made too 
narrow and its sides too tense by traction upon them. The eifect of 
traction to narrow the opening can be demonstrated on the cadaver 
(Streubel, loc. cit., p. 70) by producing a subcoracoid dislocation of the 
humerus or an obturator or ischiatic dislocation of the femur, exposing 
the region by removal of the muscles, and then making traction in the 
extended position. As the capsule is made tense the sides of the 
longitudinal part of the rent are drawn together, and their lateral 
separation, which alone would allow the globular head of the bone 
to pass back, is prevented. The narrowness of the gap is at once 
relieved by changing the position of the limb in such a manner as 
to bring the points of attachment of the capsule nearer together, and 
the transverse portion of the rent can be lengthened by rotating the 
limb. 

Interposition of the capsule between the head and its cavity may 
exist whenever a secondary displacement has succeeded the primary 
one and the head has moved from the point at which it escaped along 
the outside of the capsule, but unless the capsule has been so torn as 
to form a flap adherent by its base to the edge of the articular cavity, 
this interposition can be readily avoided by moving the head of the 
bone back to the position of primary displacement. If, on the other 
hand, such a flap has formed and has fallen between the articular sur- 
faces, there is no means, short of an operation that directly exposes it, 
of certainly getting it out of the way ; it is attached to only one bone, 
and consequently cannot be acted upon by moving the other or changing 
the relations to each other of the two. 

Swelling of the soft parts interferes with reduction by increasing the 
bulk of the limb within the fascia and thereby mechanically opposing 
changes in position. If it is very great it may be proper to defer 
reduction and combat the swelling by rest, cooling lotions, and press- 
ure ; it will usually subside so promptly that the loss of time thus 
incurred will not add appreciably to the difficulty of reduction when 
it is undertaken. 

Contraction of the muscles, provoked by the traumatism or the fear 
of pain, opposes reduction by preventing the preliminary changes of 
position and neutralizing to a greater or less extent the traction that is 
made upon the limb. It may be overcome by gentle and long-continued 
traction, or forcibly, or by anaesthesia, or it may be avoided by taking 
the patient unawares or distracting his attention at the critical moment. 

Anaesthesia is far from being needed in all cases, and as there are 
certain discomforts and even dangers in its use an attempt to reduce 
without its aid should usually be made. In New York, and, I think, 
in most of the large cities of the United States, ether is habitually used 
in preference to chloroform, and although chloroform is still used in 
Europe, the greater safety of ether is almost universally admitted. 
The collected cases of death under chloroform apparently proved the 



462 DISLOCATIONS. 

correctness of an opinion quite generally held that its use in disloca- 
tions is especially dangerous, although no satisfactory explanation of 
the fact has yet been given. Of 101 fatal cases collected by Kappeler 1 
between 1865 and 1876, 11 were dislocations, 20 amputations, and 11 
operations upon the eyes ; of 134 cases collected by Marchand, 2 17 were 
dislocations, and 15 extractions of teeth. It is not always necessarv 
to push the use of ether to complete ansesthetization, for the relaxation 
is sometimes sufficient during the stage of primary anaesthesia if care 
is taken not to excite the- patient unduly. Gentle traction may be made 
upon the limb as the anesthetization is begun, and its direction gradu- 
ally changed or merged into the desired manoeuvres as the muscles are 
felt to yield. 

Methods of Reduction. 

Since the nature of the obstacles to reduction has been more correctly 
understood the methods by forcible traction have been so far superseded 
by the methods of manipulation that they now possess only an histor- 
ical interest. They consisted essentially in extension (traction), usually 
in the line of the dislocated limb, and counter-extension to bring the 
head of the bone down to the level of its cavity, followed then by 
measures of " coaptation " to force it into place. The traction was 
made through bands attached to the lower segment of the limb, and 
the force was exerted either directly by the hands of several assistants 
or indirectly through pulleys or screws. The amount of force some- 
times exerted by these means can be inferred from the disastrous and 
even fatal consequences that occasionally ensued, including rupture not 
only of muscles and ligaments but also of the principal nerves and 
bloodvessels, and even complete avulsion of the limb. Suppuration 
of the joint, followed by the death of the patient, an accident which is 
now very rare, was formerly quite common, and in very many of the 
cases which recovered the record plainly shows the violence of the 
reaction and how narrowly the patients escaped with their lives. The 
occasion for the exertion of so much force arose from the faulty direc- 
tion in which it was frequently applied, one in which the head of the 
bone could not be brought down to the level of the cavity without 
preliminary rupture of the opposing soft parts. The laceration caused 
by the dislocation was increased by the treatment, in order to enable 
the bone to follow a course which the ligaments, if untorn, would 
effectually bar. The method was directed against an obstacle, the 
resistance of the muscles, which was only one, and that not the chief, of 
those which opposed reduction, and was pursued in ignorance of the 
principal one ; violence was used to overcome an obstacle which correct 
anatomical knowledge would have enabled the surgeon to avoid. 

It must not be understood that this extreme violence was exerted in 
every case. In many the traction was made in a proper direction, or 
at least in one in which the already existing laceration of the capsule 
allowed the bone to be moved ; hence, many dislocations were reduced 

1 Kronlein : Loc. cit., p. 66. 

2 Marchand : Des Accidents qui peuvent compliquer la Reduction des Luxations trau- 



matiques, 1875, p. 134. 



TREATMENT. 463 

with comparative facility, especially those of the shoulder and those of 
the hip in which consecutive displacement had not materially changed 
the posture of the limb, and in such cases traction was a proper means 
to overcome the opposition of the muscles. It was in such cases, too, 
that the methods of continuous moderate traction by India-rubber, 
weight and pulley, and suspension by the limb (" pendel-methode ") 
were successfully employed, and will still be when it is desired to avoid 
recourse to the aid of anaesthesia. 

As long ago as in the time of Hippocrates (fifth century B. c.) it 
had been known that some dislocations of the hip could be readily 
reduced by manipulation without the aid of violent traction, and Galen 
(second century A. D.) had pointed out that the head of the bone 
should be returned to its cavity along the route by w r hich it had escaped, 
yet these suggestions remained unknown or unheeded and the practice 
of surgery, as regards dislocations, appears to have been not only inef- 
fectual to relieve in a large proportion of cases, but also characterized 
by dense ignorance of their pathology and by the crudest notions of 
the mechanical effects of the means by which their reduction was 
attempted. Thus, among the methods in vogue, according to Petit, 
for the reduction of dislocations of the shoulder, at the beginning of 
the eighteenth century, were those of the door or ladder, the bar, and 
the ambi. In the former the patient w T as made to stand upon a 
stool, and the dislocated arm was brought over the top of a door 
or a rung of a ladder so that the latter occupied the axilla; then, 
while an assistant grasped the wrist and drew it directly downward, 
the stool was taken away and the patient left suspended until the sur- 
geon pronounced the dislocation reduced or abandoned the attempt. In 
other cases the patient was lifted from the ground upon a bar supported 
on the shoulders of two men and passing under his axilla; or a large, 
strong man seized the patient's wrist, placed his own shoulder under 
the axilla, and then suddenly straightening himself raised the patient 
from the ground, at the same time drawing the arm down forcibly in 
front of himself. The method of the heel, so strongly recommended by 
Sir Astley Cooper, was also employed by them, and sometimes with 
success. 

The ambi, an instrument invented by Hippocrates, was also in favor ; 
it consisted of two oblong pieces of wood joined together at the end by 
a hinge, of which one was placed vertically against the side of the 
patient, the hinge pressed well into the axilla, the other under the 
arm in the position of horizontal abduction. The arm was then firmly 
secured to the latter piece and forcibly depressed. 

As the defective mode of action of these methods became more gen- 
erally recognized, traction by the hands of assistants or by pulleys 
or by other apparatus was substituted, but although this was an im- 
provement upon its barbarous predecessors it was still employed 
blindly, and evidently was often ineffectual. There are indications in 
the older writings that the practice was not so wholly bad as the teach- 
ing, that here and there men were found who not only appreciated the 
importance of the direction in which traction should be made, but even 
occasionally reduced dislocations by manipulation alone, but the writer 



4(34 DLSLOCATIOJN& 

who seems to have been the first to recognize the importance of the 
principle enunciated so long before by Galen of bringing back the head of 
the bone by the route along which it had escaped, and of the position to be 
given to the limb during the attempt, was Jean Louis Petit. His Traite 
des Maladies des Os was published in 1705 ; a second edition followed 
in 1723. and a third in 1741. He clearly pointed out the mechanical 
defects of the methods then in use, and the necessity of first bringing 
the head of the bone back to the opening in the capsule through which 
it had escaped before attempting to replace it in its cavity ; and he drew 
from observation of the different degrees of tension of the different 
muscles inferences as to the position in which the limb should be placed 
and the direction in which traction should be made, which were of 
great practical value, although based upon notions concerning the 
obstacles that opposed reduction which were incomplete in that they 
took no account of the untorn ligaments and capsule. Thus, in dislo- 
cation forward or downward of the shoulder he abducted the elbow 
widelv, and in those of the thigh backward he flexed the limb and 
then changed its position when the head of the bone had been brought 
down to the proper level. 

Petit, in thus departing from the practice of his predecessors and 
contemporaries, had entered upon the right path : he erred in not fol- 
lowing it far enough, and his error arose from a too limited notion of 
the obstacles to be overcome. He noticed that some muscles were tense 
and others were relaxed, and he sought to place the limb in a posture 
that would remove these differences, while at the same time traction 
made in the direction of its long axis would bring the head of the bone 
to the point at which it had escaped from its cavity. His improve- 
ments were appreciated, and his practice was essentially followed by 
most surgeons until within the last few years. Yet one of his earlv 
successors. Pouteau. 1 in a paper embodying ideas conceived in 1749 
(see loc. cit.. vol. ii. p. 237), pointed out the defects of the method as 
applied to dislocations of the hip, and supported his own arguments 
and modifications by the record of several successes. He says ip. 222 
that in the first case of dislocation of the hip upward and outward (on 
the dorsum of the ilium | which he was called upon to treat he em- 
ployed Petit's method and failed. That is, he made traction with 
the limb somewhat flexed, counter-extension being furnished by the 
canvas band of Petit's machine, the centre of which pressed against 
the tuberosity of the ischium, while its ends lay, one in front of the 
abdomen, the other behind the buttock. The reflections excited by 
this failure led him. when the next case presented itself, a few months 
later, to make traction with the thigh flexed at a right angle, and the 
effort was promptly successful. He placed the patient on his back on 
the floor, laid the canvas band along the groin, with one end between 
the thighs and the other on the outer side of the injured hip, flexed the 
thigh to a right angle, engaged the ends of the bars in the pockets of 
the counter-extending band, and made traction ; when he deemed the 
traction sufficient, he gently rotated the thigh outward, and reduction 
at once took place. Furthermore, he showed that the resistance of the 

1 Pouteau : CEuvres posthumes. Paris. 1753. Pouteau died in 1775. 



TREATMENT. IQb 

muscles was due to their involuntary contraction and was to be more 
readily and safely overcome by prolonged moderate traction than by 
more violent but briefer efforts. He says (loc. cit., p 226) : " I have 
several times observed that it is easier to temporize than immediately 
to overcome the resistance of these muscles ; so, when the extension 
seems to be sufficient I maintain it at the same point for some time and 
wait for the relaxation which fatigue must bring about. It is then only 
necessary to profit by this moment of inaction to effect the reduction." 

Pouteau's practice closely resembled that which represents the appli- 
cation of the principles of the modern method by manipulation, and is 
identical with that of moderate traction upon the flexed limb which is 
now in common use and is, I think, generally preferred to that of pure 
manipulation. He flexed the limb to bring the head of the bone nearer 
the opening in the capsule, made traction to lift it to the level of the 
cotyloid cavity, and then turned it in by outward rotation or abduction, 
or both. He knew even that the traction could sometimes be dispensed 
with and the reduction effected by manipulation alone, and, in quoting 
successes thus obtained by Maisonneuve, he predicts that a simpler 
method than his own will be found. The failure of his practice to 
become generalized is probably due to the influence of tradition and of 
the authority of Petit, reinforced as the latter was by the great advance 
he had made over the practice of his predecessors, and perhaps to the 
insufficient publication of Pouteau's views. The paper from which 
the above quotations are made appears to have been written in 1749, 
but there is no evidence that it w T as published elsewhere than in the 
posthumous collection of 1783, which, consisting of disconnected essays 
upon various subjects, probably had only a limited circulation. What- 
ever the cause may have been, the result is beyond question ; surgeons 
continued to reduce dislocations of the hip by traction with the pulleys, 
the limb being only slightly flexed, and by pressure applied at the 
upper part of the thigh to move the head laterally into the cavity. Sir 
Astley Cooper habitually used only traction, followed by rotation of 
the thigh inward. 

Prof. Nathan Smith, of New Haven, taught and practised a method 
of reduction by manipulation which was published in 1831 after his 
death, in his Medical and Surgical Memoirs, edited by his son, Nathan 
P. Smith, and this, Prof. Bigelow says, " covers the ground of priority 
of invention." (See Chapter LI., Treatment.) 

The next published recognition of the possibility of reducing a dis- 
location of the hip by manipulation alone was by Despres, who, in 1835, 
communicated to the Soci6te Anatomique of Paris 1 "a new method of 
reducing dislocations of the femur " by flexion and rotation outward. 
The only comment it excited at the time, according to the records of 
the society, Avas the mention a few months later by Pigne of the fact 
that the same method was described by Beach in a Treatise on Medi- 
cine, published in New York in 1833, and was there said, on the 
authority of Sweet, the "natural bone-setter," to have been practised 
by the savages of North America. 2 The Despres incident is mainly 

1 Despres: Hull, de la Soc. Anatomique, September, is;>r>, p. 4. 

2 Beach, like Sweet, appears to have been an irregular practitioner, ami it is likely that 
his assertions, even when known, were not deemed worthy of serious consideration. 

30 



466 DISLOCATIONS. 

noteworthy as showing how completely the previous suggestions had 
been forgotten or overlooked, even by Pouteau's ow t ii countrymen. It 
is now used by the French as a justification for speaking of the method 
by manipulation (at the hip) as the " Methods de Despres." 

In like manner, other surgeons sought to modify the practice as 
regarded the shoulder-joint, by advising that the traction should be 
made in different directions and combined with rotation of the limb. 
Of these the most noteworthy are Mothe and Lacour, since it is with 
their practice that the manipulative methods are generally thought to 
have begun. 

The earlier manipulative methods were either empirical or based 
upon more or less incorrect notions of the nature of the obstacles to be 
overcome and of the mechanism by which the result was to be obtained, 
and it is only since the pathology of the different dislocations has been 
better understood, with reference especially to the position of the rent 
in the capsule and the influence of the portions which remain untorn, 
that the different procedures embraced under this method have been 
intelligently devised and executed. They differ so widely in their 
details that only the most general description can be given here ; they 
consist in giving to the limb successive positions, by which the head of 
the bone is first brought opposite the opening in the capsule and then 
into its cavity, and by which the opening in the capsule is made to 
gape widely, or is actually enlarged if necessary. For the accomplish- 
ment of these ends the limb is used as a means of acting upon the cap- 
sule so far as it remains attached to the bone, and the head of the bone 
is made to take its successive positions by rotation of its shaft, or by 
using it as a lever which finds its fixed point either upon some adjoin- 
ing prominence of bone or in the capsule, or by moving the entire limb 
in the direction of its long axis. Combined with these manipulations 
it is commonly necessary to employ a certain amount of traction to over- 
come gravity or such resistance as is offered by the muscles. 

It rests essentially upon an anatomical and pathological basis con- 
sisting of two parts, the position of the rent in the capsule and the 
resistance of the untorn portion, and depends for its knowledge of these 
two factors, in any given case, mainly upon the position occupied by 
the limb and the limitations of the movements. Resistance of the 
muscles, when present, is overcome by ansesthesia or by traction. 

Such traction as is required is made by the hands of the surgeon or 
of an assistant, or by the weight of the dependent limb, or by the pro- 
longed action of an elastic band or of a weight suspended over a pulley. 

Continuous traction by India-rubber bands was introduced by Legros 
and Onimus while internes in the Paris hospitals, 1863 to 1866, and 
advocated by them in a paper published in 1868. 1 They recognized 
that their object, the fatigue of the opposing muscles, could be equally 
well accomplished by weight and pulley or a steel spring, but they gave 
the preference to India-rubber because of the ease with which it could be 
used. Their reported cases are dislocations of the shoulder and elbow. 

The method of application in dislocations fonvard of the shoulder, 

1 Legros and Onimus: Des Tractions continues, et de leur Application en Chirurgie. 
Arch. Generates de Med., January, 1868. 



TREATMENT. 467 

for example, is as follows : A loop is made fast to the lower part of the 
arm by turns of a roller-bandage or by strips of adhesive plaster as in 
Buck's extension ; then the patient is seated in a chair, counter-exten- 
sion provided by a band passing around the chest under the axilla and 
over the opposite shoulder and made fast to some neighboring fixed 
point, the elbow gently raised to or nearly to the position of horizontal 
abduction, and traction made in the direction of its long axis by a 
rubber cord passed through the loop attached to the arm and around a 
fixed point established in an appropriate position. The traction should 
be about twenty or twenty-five pounds, and needs to be continued for 
from fifteen to thirty minutes ; under its influence the muscles become 
relaxed and the patient experiences the sensation of great fatigue, the 
head of the bone gradually approaches the glenoid cavity, and either 
enters it spontaneously or is replaced by the pressure of the surgeon's 
fingers, or by a sudden pull upon the arm. 

Continuous traction by the iveight of the limb is used at the hip and 
shoulder. The limb is placed in such a position that its weight tends 
to move it in the desired direction ; thus the thigh is allowed to hang 
down (the knee flexed and the leg horizontal) at the end of a table 
upon which the body of the patient lies prone. For the shoulder, the 
patient is placed upon his side on a cot through a hole in which the 
injured arm hangs directly down. To the weight of the limb in 
either case that of a sand bag may advantageously be added. (See 
Chapters XLII. and LI.) 

Athrotomy. Occasionally a fresh dislocation is irreducible because 
of an exceptional position of the bones or of interposition of the soft 
parts. I have seen this once each at the shoulder, elbow, and temporo- 
maxillary joints, and a number of times at the metacarpophalangeal 
joints and in dislocations with fracture. At the shoulder the head of 
the humerus had passed below and then so far to the inner side of the 
subscapulars that its tendon was closely wrapped about the outer side 
of the neck of the bone and had to be divided ; at the elbow, apparently 
in consequence of repeated attempts to reduce, the denuded end of the 
humerus had been forced through the fascia in the flexure of the joint, 
and the tendon of the biceps was lodged behind the external condyle ; 
at the jaw, the meniscus had been torn away from the condyle and was 
lodged behind it. 

If such an operation is done within a day or two after the accident 
the risk is no more than that of a similar opening of the unlacerated 
joint; but while inflammatory reaction is active and oedema is marked 
the chance of suppuration is greater, and it is then well, I think, to 
await their subsidence before operating. 

Old Unreduced Dislocations. 

The changes, above described, which take place about a dislocated 
bone gradually increase the difficulty of reduction by means that arc 
sufficient while the dislocation is fresh, and ultimately make it impos- 
sible. The conditions vary so greatly with individual cases ami with 
the different joints, and their extent and detail arc so unrecognizable 



468 DISLOCATIONS. 

clinically and so largely a matter of inference that the difficulty cannot 
be measured simply by the length of time that has elapsed, and too 
often not even by anything short of an actual trial. 

The common practice, until within quite recent times, was simply to 
employ the usual forcible means more forcibly, to rupture adhesions by 
forcing the limb in various directions, and then to drag it into place by 
pulleys or specially devised apparatus. While this succeeded in many 
cases, and even occasionally in some at the shoulder and hip which had 
existed for months, yet the record is full of accidents and disasters, 
and many a grave warning has been uttered against the dangers of the 
attempt even in apparently suitable cases and against the temptation to 
subordinate the patient's welfare to a desire to obtain an unusual success. 

The dangers of forcible reduction in cases of long standing, and the 
superiority of operative methods to meet the special indications that 
may exist in them, are now so well understood that the warning is not 
much needed in such cases ; it is in the more recent cases, those of a 
few weeks, that it is now specially necessary to be on guard against 
being unwittingly led to strive too long, to make a stronger and still a 
stronger pull after less force has failed. The danger is specially great 
in the old, whose diseased arteries may so easily be bruised or torn, 
and whose thinned bones may so easily be broken. The following 
two cases which recently occurred in the service of a surgeon in a 
prominent New York hospital, within a year of each other (1896-97), 
illustrate the temptation and the risk. 

A woman sixty-seven years old ; subcoracoid dislocation two weeks 
old. Ether ; traction by pulleys, estimated at 300 pounds ; reduction 
on second attempt. The following day the radial pulse could not be 
felt, and gangrene seemed imminent ; seven weeks later amputation of 
the arm ; death. The autopsy showed a thrombus in the brachial 
artery. 

Man sixty-eight years old ; subcoracoid dislocation six weeks old. 
Ether ; manipulation to rupture adhesions ; Kocher's method tried 
twice, then heel in the axilla. Then arm carried forcibly across the 
body, the head slipping to the outer side of the glenoid fossa ; finally 
traction in abduction succeeded. Died five hours later. Autopsy 
showed rupture of the axillary vein and of the short head of the 
biceps ; capsule entirely torn from the humerus ; third, fourth, and 
fifth ribs fractured in the axillary line. 

The alternative measures — reduction by operation, excision, and 
osteotomy — have been made so much safer than formerly by improved 
surgical technique that they are now resorted to with increasing fre- 
quency, and the resulting experience has been such that rules of treat- 
ment can be formulated for some of the joints. In backward dislocation 
of the elbow formal exposure by two lateral incisions and removal of 
the cicatricial tissue permit complete reduction and usually a notable 
improvement of function. At the shoulder the range of motion after 
reduction by operation has generally been small, and the operative 
difficulties are often great ; excision of the head gives greater mobility 
and meets the frequent special indication of relief of pain due to press- 
ure, but the result is marred by the diminution of active control. At 



TREATMENT. 469 

the hip reduction by operation has proved dangerous and has failed in 
more than half the trials ; even when it has succeeded the functional 
gain has not often been notable. (See Chapter LIU.) 

The facts and general principles to be considered in determining upon 
resort to operative interference and in making a choice of methods are 
as follows : 

1. At the present time wound infection is of more frequent occur- 
rence after operative reduction of old dislocations of the large joints 
than in other primarily clean operations, and an almost inevitable 
result of such infection is anchylosis of the joint ; and even in cases 
which escape infection the restoration of function is usually quite 
incomplete. Consequently the usefulness of the limb in the existing 
conditions and the probable gain by interference should be carefully 
considered. 

2. A faulty fixed position may be so improved by an operation that 
the usefulness will be increased even if anchylosis follows. 

3. On the other hand, and this is specially true of the hip, the im- 
provement to be got by a change of position may be far too slight to 
justify the risks of an operation so extensive as would be required for 
reduction, and an almost equal improvement might be had by an oste- 
otomy. 

4. Pain and trophic changes in the limb due to pressure upon nerves 
are good reasons for interference ; the relief would probably be more 
surely and easily obtained by an excision of the head of the bone. 

5. Excision, when undertaken only to improve function, is suitable 
at the shoulder and elbow, but must be sparingly employed at the hip 
where solidity of support is more important than mobility. 

After-treatment. 

After a dislocation has been reduced, there is needed, in most cases, 
only a simple retention bandage to confine the limb in an easy position, 
but in some cases — dislocation of either end of the clavicle, of the 
head of the radius, and sometimes of the shoulder backward under 
the spine of the scapula (Busch and Kronlein) — the tendency to recur- 
rence is so great that special dressings are required. The joint should 
be kept quiet, certainly any movement that causes pain should be 
avoided, and if the inflammatory reaction threatens to be severe it 
must be opposed by the application of cold, or uniform gentle press- 
ure if it can be borne. After a week or two the use of the limb may 
be gradually resumed. In making passive motion or this use of the 
limb, those positions must be avoided in which the head of the bone 
would press upon the torn part of the capsule, or in which the sides 
of the rent would be again separated from each other. 

If, as sometimes happens, the joint remains stiff, weak, and sensitive. 
but is cold rather than warm, and aches and perhaps becomes puffy 
after use, it needs massage and rubbing, and to be actively moved 
either by the patient or by the physician. Its sensitiveness and immo- 
bility under such circumstances an 1 due to the prolonged disuse, \o 

1 For many cases of various forms of operation see Engel, in Arch, fur klin. Chir., 
1897, vol. lv. p. 603. 



470 DISLOCATIONS. 

retraction and loss of pliability in the peri-articular tissues, and possibly 
to the presence of adhesions within the cavity itself. 

Habitual Dislocation. 

A marked tendency to recurrence may be combated by prolonged 
immobilization of the joint if the injury is comparatively recent, or 
by special treatment designed to thicken and shorten the capsular and 
peri-articular tissues. Genzmer 1 successfully employed in two cases of 
recurrent dislocation of the shoulder repeated injections into the joint 
of the pure tincture of iodine. The needle was introduced a finger- 
breadth below the coracoid process, and seven to ten minims were in- 
jected. The arm was then immobilized, and the injections repeated 
from five to seven times at intervals of three or four days. He 
recommended the same treatment for habitual dislocation of the 
lower jaw. 

Dubreuil 2 reports a cure at the shoulder by six injections, during a 
fortnight, of two drops each of a 10 per cent, solution of chloride of 
zinc into the peri-articular tissues. At the sternal end of the clavicle 
I have twice obtained a good result by injecting a few drops of alcohol 
into the peri-articular tissues and immobilizing for a fortnight. 

The operative method which seems safest and most efficient at the 
shoulder is one introduced by Bicard, 3 the formation of a permanent 
fold in the anterior portion of the capsule by three vertical silk sutures. 
A similar method has been used in habitual outward dislocation of the 
patella. See also Chapter XLIY. 

1 Genzmer : Centralblatt fur Chirurgie, 1883, p. 563. 

2 Dubreuil : La Semaine Med., February 27, 1892. 

3 Kicard : Acad, de Med., October 31, 1892. 



PLATE XLIX 




Fig. 1. — Fracture of Os Calcis. 







Fig. 2 — Fracture of Upper Posterior Portion of Os Calcis by Avulsion. 



CHAPTER XXXIV. 

ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE 

A DISLOCATION. 

The complications or accidents that may be caused by the attempt 
to reduce a dislocation may appear during the attempt, as the imme- 
diate consequence of the manoeuvres employed, or subsequently as a 
more or less remote consequence of the changed conditions, the local 
injuries, or the inflammation produced by those manoeuvres; and they 
may be localized at or near the dislocated joint, or may be the result of 
a local distant change or of a more diffused impression upon the organ- 
ism. They may, therefore, be grouped as : 1st, primary local accidents ; 
2d, consecutive local accidents ; 3d, cases of hemiplegia, syncope, and 
sudden death. The first group comprises injuries of the skin, cellular 
tissues, muscles, vessels, nerves, and bones ; the second group includes 
suppuration in or about the joint, and oedema, gangrene, and paralysis 
consequent to injury to vessels or nerves. The third group includes 
those cases of shock or exhaustion, sometimes proving fatal, which 
have become exceedingly rare since the introduction of anaesthetics, 
and those others, that have come in their place, of death due to the 
anaesthetic itself. 

It is noticeable, on comparison of the cases that have occurred at 
different periods, that while some varieties of the lesions are common 
to all times, with their varying methods of treatment, others are in a 
manner dependent upon the means by which the reduction has been 
attempted. Thus, violent traction is the sole cause of some ; manoeu- 
vres, such as abduction and rotation of the arm, the principal cause of 
others ; violent pressure at or near the head of the bone, prolongation 
of the effort, and anaesthetics, each of its own peculiar varieties. Not- 
withstanding these differences, certain points may be recognized as 
common to the greater number, such as the age of the patient and the 
length of time during which the dislocation has remained unreduced. 
Injuries of the vessels have been most frequent in the old and in dis- 
locations of long standing, and all the other accidents have, in recent 
times at least, been rarely seen except in connection with dislocations 
that have long remained unreduced or that have been complicated by 
much inflammatory reaction. The reasons for the greater liability to 
rupture of the arteries under these conditions are not obscure ; the loss 
of elasticity because of atheromatous change in the vessels in the old, 
and the adhesion of the vessels to adjoining parts as a sequence of 
inflammation are a sufficient explanation, and the mechanical difficul- 
ties created by the contraction and readjustment oi' the torn tissues in 
old dislocations explain the others by the force that is required to over- 
come them. 

471 



472 DISLOCATIONS. 

Integument. The skin may be bruised or lacerated at a distance from 
the joint by the pressure of the cords through which traction is made, 
or near the joint by the pressure of the hands or instruments acting 
upon the dislocated end of the bone, or it may be torn across if the 
traction is exerted upon it rather than upon the bone. These lesions 
are seldom serious, and the former may usually be avoided by protect- 
ing the surface with thick layers of cotton or flannel. Transverse 
rupture of the skin between the points of extension and counter-exten- 
sion is due to a faulty application of the force, by which it is exerted 
upon the skin alone and not upon the underlying bone. The skin is 
elastic and tough, and when unaltered by disease will support a very 
considerable strain, one far in excess of that commonly needed to over- 
come the contraction of a muscle, but the traction may be so applied 
that it will act only upon the skin. Thus, if a broad band is strapped 
snugly about the middle of the arm and traction is made by a cord 
attached to it, it will draw the skin downward toward the elbow ; and 
if at the same time the skin of the axilla and chest-wall is prevented 
by counter-extension from sharing in the movement, the intermediate 
portion is put upon the stretch and may tear. 

To guard against the occurrence of this accident the limb should be 
firmly grasped, if traction by the hands is used, at the enlarged distal 
end of the bone, so that the skin should not be drawn downward by 
the slipping of the hands, and the additional precaution may be taken 
to press the skin of the forearm (in the case of a shoulder dislocation) 
upward before the limb is grasped, and similar precautions suitable to 
the region should be taken at the point of counter-extension. If trac- 
tion is made by a cord or band, it should be attached to the limb just 
above a bony prominence or enlargement which will prevent its slip- 
ping ; it should not be made fast simply by enclosing its loop in 
circular turns of a bandage which maintain their hold upon the skin 
by friction. 

Sloughing of the skin, due to its compression against an underlying 
bone by direct pressure exerted to force the latter back into place, has 
been occasionally observed, in a dislocation of the astragalus, 1 and over 
the olecranon in an attempt made by a bonesetter to reduce a backward 
dislocation of the elbow. 

Emphysema of the Cellular Tissue. This has been noted in one 
case. Flaubert 2 reduced a dislocation of the shoulder of five weeks' 
standing in a woman seventy years old ; the first attempt was unsuc- 
cessful ; in the second traction was made by eight students, and the 
patient, who at first uttered vehement cries, seemed afterward to be 
upon the point of suffocating, and her face became purple and injected. 
An emphysema immediately appeared above the clavicle and spread 
over the shoulder to the middle of the back. She died on the 
eighteenth day, apparently in consequence of the tearing away of the 
lower four trunks of the brachial plexus at their attachment to the 
spinal cord. 

1 Dauve : Rec. de Mem. de Med. et Chir. Milit., 1867, vol. xix. p. 143. 

2 Flaubert: Repertoire d'Anat. et de Phys., 1827, quoted by Malgaigne. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 47:i 

Rupture of the Muscles. Under this head only those lacerations 
of the muscles will be mentioned which are occasioned, especially in old 
dislocations, by violent traction or by forcible, exaggerated, and long- 
continued manipulation of the limb. The cases in which the injury 
has been confirmed by autopsy are few, only those in which death has 
promptly followed in consequence of associated lesions or of the inflam- 
mation to which the violence has given rise. Yet, in another of Flau- 
bert's cases, 1 there seems to be no doubt that not only the muscles but 
also the ligaments and other soft parts were extensively torn. The 
case was one of dislocation of the elbow backward, twenty-seven days 
old, in which traction was made upon the forearm by seven assistants ; 
suddenly the parts seemed to yield and change their positions with a 
sound of tearing, and at the same moment a zone of narrowing or 
depression appeared at the level of the joint with a bony prominence 
above and below. It seemed to all present that the muscles and soft 
parts covering the joint had been ruptured, leaving a gap two inches 
long. An enormous fluctuating swelling promptly appeared, the radial 
pulse returned the next day, and the patient recovered. 

In the cases confirmed by autopsy the dislocation has always been 
of the shoulder, and the muscles most frequently torn have been the 
pectoralis major and the subscapularis. 

Avulsion of a portion of a limb is fortunately a very rare accident. 
Except for one or two cases of avulsion of the thumb, known only by 
tradition, the only instance of complete avulsion is that in which 
Alphonse Guerin tore away the forearm at the elbow in an attempt to 
reduce a subcoracoid dislocation of the shoulder of six weeks' standing. 2 

The rupture took place mainly through the joint, a small portion of 
each condyle remaining attached to the muscles of the forearm, and a 
portion of the olecranon to the triceps. The muscles were softened 
and brown ; the nerves were injected, with nodes at intervals ; the veins 
were dilated. The ends of the long bones were profoundly disorgan- 
ized, with thinning of the compact shell and rarefaction of the spongy 
part ; they broke under slight pressure and could be easily perforated 
with the scalpel. Microscopical examination showed degeneration of 
the nerves, muscles, and bones. 

The patient died on the thirteenth day, and the autopsy showed no 
change in the tissues of the other limbs ; the muscles of the shoulder 
were normal, except the deltoid, the fibres of which were pale and 
degenerated. The nerves were matted together in the axilla and firmly 
pressed against the head of the humerus ; above the point of compres- 
sion they were normal, contrasting strongly with the parts below. 

It is evident that the accident was favored by great trophic changes 
in the limb, probably due to pressure upon the nerves in the axilla. 

Injuries of the Main Bloodvessels. Although the earliest recorded 
cases of accidents of this class occurred at about the beginning of the 
eighteenth century, the subject did not receive the attention oi' sys- 

1 Malgaigne: L<Jc. cit., p. 149. 

' l GruSriti : Hull, de la Soc. de Chir., 1864, pp. 121 and 131. 



474 DISLOCATIONS. 

tematic writers on surgery until after the publication, in 1827, of an 
article by Flaubert. 1 Malgaigne, in 1855, discussed the subject at 
length in his work on dislocations, mentioning sixteen cases of all 
kinds, certain and uncertain. Callender, 2 taking as a text his own 
fatal case, again collected and collated the known cases ; and similar 
use was made of the material and other cases added to the list by Le 
Fort, 3 Willard, 4 and Marchand. 5 In 1882 Kb'rte 6 reported three per- 
sonal cases, and wrote a very full and valuable paper on the subject, 
containing forty-four supposed (actually thirty eight; see first edition, 
p. 79) cases of dislocation of the shoulder in which the vessels had been 
seriously injured during the act of dislocation or of reduction ; and in 
1884 Cras" reported a personal case of injury of the axillary artery, 
and added a few others to Korte's list. Strictly speaking, several of 
these cases should not be here considered, since in them the vessel was 
injured at the moment of dislocation and not during reduction, and in 
many others it remains uncertain whether the same objection might not 
be made to them. They are retained because they serve equally well 
with the others to further the study of most features of the subject. 

I have met with only two recorded cases in which a large bloodvessel 
has been injured in the reduction of any dislocation except of the 
shoulder. These were both of the elbow, the cases of Flaubert and 
Michaux, quoted by Marchand and Malgaigne. The former has been 
already quoted under rupture of the muscles ; in the latter the patient 
Avas ten years old, and the dislocation was of the elbow backward and 
outward, the swelling was considerable, the radial pulse was present. 
Reduction was attempted on the day after the accident, and on the 
next following day, but without success. The last attempt was imme- 
diately followed by swelling of the elbow and by arrest of pulsation in 
the radial and ulnar arteries ; gangrene set in, and six days after the 
attempt the limb was amputated. The tendons of the biceps and 
brachialis anticus were found to have been forced by the manipulation 
around the external condyle to the posterior aspect of the humerus, 
accompanied by the ruptured brachial artery and median nerve. 

In 1885 I 8 found forty-seven trustworthy accounts of injury to the 
larger vessels of the axilla in dislocation or reduction of dislocation of 
the shoulder. Since then Caldwell 9 has reported a case thought to be 
rupture of the anterior circumflex artery, and I have learned of one of 
rupture of the axillary vein (Weir). The latter has been quoted above 
(p. 446). CaldwelPs patient was fifty-eight years old, and the disloca- 
tion had been promptly reduced. Six weeks later " there was a large 
fluctuating swelling in the outer aspect of the shoulder, over the area 
covered by the deltoid ; " pulsation at wrist and in axillary artery ; no 

1 Flaubert : Mem. sur plusieurs cas de luxations dans lesquels les efforts pour la reduc- 
tion ontete suivis d'accidents graves, Eepertoire d'anat. et de phys., 1827. 

2 Callender: St. Bartholomew's Hospital Reports, 1866, vol. ii. p. 96. 

3 Le Fort: Diet, encvclopedique des sci. med., article Axillaires. 

4 Willard: Philadelphia Medical Times, 1873, vol. iii. p. 721. 

5 Marchand : Des accidents qui peuvent compliquer la reduction des luxations traumat- 
iques, These de concours, Paris, 1875. 

6 Korte (first paper) : Arch, fur klinische Chirurgie, vol. xxvii. p. 631. 

7 Cras: Bull, de la Societe de Chirurgie, 1884, p. 739. 

8 Stimson: New York Medical Journal, June 13, 1884, and first edition of this work. 

9 Caldwell : Cincinnati Lancet-Clinic, May 3, 1890. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 17 :> 

swelling in axilla. Under the impression that the swelling was due to 
an abscess an incision was made and about a pint of clotted blood evacu- 
ated ; this was followed by arterial hemorrhage, arrested by pressure of 
the thumbs in the wound. The wound was enlarged, but the source of 
the bleeding was not found. The wound was packed with gauze, and 
the patient recovered. In 1901 Korte 1 reported another personal case 
and collected five not included among those already mentioned, and in 
1905 Hessmann 2 one of rupture of the axillary artery, in a man sev- 
enty-two years old. He ligated the subclavian artery, and a fortnight 
later disarticulated the limb. Recovery. 

Of these, the axillary vein alone was ruptured in four (Froriep, Price, 
Weir, Hailey), although I think the last one doubtful, and the artery 
and vein together in three (Platner, Baum, Sonnenburg). 3 In most of 
the others the axillary artery or one of its branches was injured, but 
in some the source of the hemorrhage remains uncertain. In thirty- 
five cases death or amputation of the arm furnished the opportunity 
to examine the region and determine the character of the lesion ; 
this, in some cases, was a complete or partial rupture of all the coats 
of the artery or of the inner and middle coats alone, with subse- 
quent formation of a circumscribed aneurism. In other cases the 
vitality of the wall appears to have been diminished or destroyed by 
direct pressure, and this to have been followed, after the lapse of a 
few days, by rupture, or, still later, by the formation of an aneurism. 
In Gibson's second case an aneurism appears to have formed in conse- 
quence of the earlier attempts to reduce, and then itself to have been 
ruptured when Gibson effected reduction. Rupture always appears to 
have taken place quite high up, and usually at the point pressed upon 
by the head of the humerus. Callender found it necessary to divide 
the pectoralis minor to reach it. In the fatal cases of injury of the 
vein alone the vessel was torn completely, or almost completely, across. 

In seven cases only a small (one-sixth of an inch) oval opening was 
found on the anterior wall of the artery, and was thought to have been 
produced by the tearing off of a branch, the subscapular or circumflex. 

In other cases the subscapular or the circumflex artery was torn 
across at or near its origin. The cases of this kind form a consider- 
able proportion of the whole number, and are of great importance 
because they explain the persistence of the radial pulse noted in several 
of the histories. In Parker's the swelling was at the axillary border 
of the scapula behind, " near the situation of the dorsal scapular artery 
or the subscapular at the junction of the two ; " in Caldwell's under the 
deltoid. 

Of thirty-four cases in which the age of the patients is given, in 
twenty-two they were more than forty years old. The youngest was 
twenty, the oldest eighty-six. In very few of the cases it is noted that 
the arteries were atheromatous, although the advanced age of many 
of the patients makes it probable that the elasticity of the vessels was 
diminished. 

1 Korte (second paper) : Arch, fur klinische Chirurgie, vol. Ixvi. 

2 Hessmann : Munchener med. Wochenschrift, 1905, No. 12. 

:! Possibly to these may be added Vblkmann's ease of wound of the axillary vein, 
thought to have been caused by a splinter of bone. The wound was discovered during 
an operation to excise the head. 



476 DISLOCATIONS. 

In more than half the cases the dislocation was recent — less than 
three weeks. In not more than one third of them it is reasonably 
certain that the lesion was caused during reduction ; in three cases it 
was certainly caused by the dislocation ; in the remainder the cause is 
obscure. To these latter belong those cases in which the reduction 
was promptly effected, and without the use of much force or of exag- 
gerated positions of the arm. In many of the others the attempt to 
make reduction was greatly prolonged or several times repeated, and 
the force used was very great or improperly applied. 

In some the injury was evidently caused by excessive traction ; in 
others by faulty manoeuvres, such as extreme abduction or elevation of 
the arm, rotation, and circumduction ; in others again apparently by 
direct compression of the vessel against the underlying bone, as by the 
booted heel in the axilla, or possibly by the thumbs. 

Leaving aside the earlier cases in which faulty methods no longer in 
use were employed, and those old dislocations in which the relations 
and connections had been permanently changed by fibrous or bony 
tissue of new formation, it becomes evident that in dislocation of the 
shoulder the accident is most to be apprehended when the elbow is 
raised in abduction to the height of the shoulder, or is carried, as in Cal- 
ender's and Weir's cases, across the chest and face in a wide movement 
of circumduction ; and for this reason, that in these movements the dis- 
located head of the bone is turned downward into the axilla, and the 
vessels which lie upon its inner side are pressed down before it and 
forcibly put upon the stretch, while those branches which run almost 
directly outward, the subscapular and circumflex, and are fixed to the 
tissues amid which they branch, are directly and forcibly elongated. 
Although in dislocation inward the limb is shortened by being ab- 
ducted, yet the artery is not thereby relaxed, but, on the contrary is 
still further stretched around the head of the bone. Jossel, 1 in a recent 
case in which death was caused by associated injuries, found the " nerves 
of the brachial plexus, especially the circumflex nerve and the sub- 
scapular artery, greatly stretched by the head of the humerus ; " and, 
according to Korte, 2 he found in another case of recent dislocation the 
subscapular artery torn. 

In some of the cases in which it is certain or probable that the injury 
to the vessels was inflicted at the moment of dislocation, it is noted that 
the latter was produced while the arm was widely abducted — that is, 
under circumstances in which the head of the humerus would be driven 
downward and inward. 

If the dislocation is an old one, and especially if there has been 
much inflammatory reaction, and the vessels have become firmly adher- 
ent to the bone or embedded in unyielding cicatricial tissue, the lia- 
bility to rupture is increased, because of the loss of elasticity occasioned 
by the latter condition, and because of the limitation of the strain to 
a shorter segment of the vessel in the former. If, in addition, the 
distensibility of the vessel has been further reduced by atheroma, the 
danger is still greater ; and this last predisposing cause may properly 

1 Jossel: Deutsche Zeitschrift, 1880, vol. xiii. p. 177. 

2 Korte (first paper) : Loc. cit., p. 640. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 477 

be deemed sufficient to lead to the rupture, even when the traction is 
slight and the manoeuvres are confined within a narrow range. 

The symptoms at the beginning present two widely different forms ; 
in one, the less common, a tumor presenting many of the signs of an 
encysted aneurism appears in the axilla a few days or weeks after 
the reduction, and increases in size rather rapidly ; if not successfully 
treated, it soon involves the skin and ruptures externally. 

In the other form, the more common, a diffused fluctuating swelling, 
without bruit or pulsation, appears immediately, or within a few hours, 
in the axilla, raising the pectoral and deltoid muscles, or is perhaps 
most prominent posteriorly, and in most cases promptly reaches a large 
size, even that of the adult head (Lister); the radial pulse sometimes 
persists. The only exception to rapid growth among the recorded fatal 
cases is Korte's third case, 1 in which the extra vasa ted blood disap- 
peared slowly, leaving a firm, non-pulsating lump, as large as a walnut, 
in the course of the axillary artery, which a surgeon supposed to be a 
lymphatic gland, and undertook to extirpate nearly five months after 
the accident. It proved to be an aneurism containing much stratified 
clot; the axillary artery was tied above and below, and the patient died. 

In several cases the patients died promptly after the accident, some- 
times after profound syncope, sometimes after a short period of appar- 
ent well-being, with symptoms of shock or acute anaemia. In two, 
which finally ended in recovery, the patients were at first greatly pros- 
trated, and death by syncope threatened. In another gangrenous 
emphysema developed in the arm, and the patient died forty hours 
after the reduction. In this case the inner and middle coats of the 
artery were torn across " just beyond the point of origin of the dorsal 
scapular branch." The radial pulse was at first perceptible, but had 
ceased the next morning. 

In most of the others the swelling increased, and, in a longer or 
shorter time, ruptured spontaneously, or was threatening to rupture 
when operative interference (puncture, incision, or ligature of the sub- 
clavian) was resorted to. The longest period was in Bellamy's case, 
six months after reduction, and even in this case the first hemorrhage 
occurred five weeks after reduction. 

In eight cases that recovered without operation, the swelling subsided, 
and the ecchymosis was slowly absorbed. Probably in some of them 
the vessel injured was one of the branches of the axillary artery, but 
in at least one (Sands) the injury was certainly of the artery itself. 

In the three cases in which rupture of the vein alone was demon- 
strated post mortem (Froriep, Weir, Price), the patients died promptly, 
in an hour and a half, five hours, and on the following day respectively. 

The histories show T that, although the diagnosis, so far as the general 
nature of the accident, rupture of a bloodvessel, is concerned, does nor 
long remain obscure, the identity of the injured vessel cannot always 
be determined. If the tumor pulsates, the diagnosis of rupture of an 
artery may be made; and if, in addition, the radial pulse is present, it 
is extremely probable that the injured vessel is not the main artery 
but that one of its branches, probably the subscapular or circumflex, 

1 Korte (first paper): Loo. tit.. i>. t;;?t;. 



478 DISLOCATIONS. 

has been ruptured or torn off at its origin. Beyond this it does not 
seem at present possible to go with much certainty, although the great 
preponderance of arterial lesions in the known cases — 26 out of 29 — 
makes it highly probable in any given case that an artery and not the 
axillary vein has been torn. 

The terminations were as follows : 22 recoveries, 33 deaths, and in 1 
(Green's) the result is unknown ; 21 received no operative treatment; 
of these 6 recovered and 15 died. 1 In 19 the subclavian was tied, 
with 8 recoveries and 1 after disarticulation, 8 deaths, and 2 unknown 
result. In 1 a cure was effected by digital pressure on the subclavian, 
and in 1 by stuffing the cavity with gauze (ant. circumflex). In 6 an 
incision was made in the axilla, and the artery tied above and below 
the point of rupture ; all died. In one (Korte's second) the small 
opening in the artery was sutured, and after a hemorrhage on the 
twenty-second day the artery was tied above and below. The patient 
recovered with a useless limb after prolonged gangrene and suppura- 
tion. In one (Raw) the torn subscapular artery and axillary vein were 
tied, the patient recovering. In 4 the limb was disarticulated ; 1 
recovery, 3 deaths. The treatment in the cases that recovered without 
operation was simply compression of the swelling and immobilization 
of the arm, with the application of ice in Malgaigne's, and compression 
of the subclavian artery in Agnew's. 

In drawing inferences from these results, it must be borne in mind 
that in many of the cases in which operations were undertaken non- 
operative treatment had previouly been employed, and had resulted 
in a condition that made an operation necessary. Including such, the 
results of non-operative treatment may be tabulated as follows : Of 
38 patients, 6 recovered, 15 died, and 17 (with 10 deaths) subse- 
quently underwent operation, either because death by hemorrhage 
threatened or because of the existence of a growing aneurism. 2 A 
fair inference from the reported cases is that conservative treatment 
may properly be tried at first, but should not be prolonged if the 
symptoms do not properly yield ; and, secondly, that, in case of 
resort to operation, ligature of the subclavian artery or disarticulation 
at the shoulder is to be preferred to incision of the sac and double 
ligature of the artery. It is not easy to understand why ligature of 
the artery above and below has been so uniformly fatal, and notwith- 
standing the record I should prefer it to disarticulation, and perhaps 
even to ligature of the subclavian. 

Experience with arteries wounded under other conditions has shown 
that they will sometimes quite readily heal, or the opening made into 
them will close, under pressure accurately made at the point of injury, 
and it would, therefore, be proper to attempt to treat this injury by 
direct, limited pressure. Whether or not it would be possible to 
recognize the wounded point and make efficient pressure directly upon 
it cannot be said, since the attempt does not appear to have been 

1 Possibly Korte's second case should be included amoug the recoveries. 

2 Korte's second case is an exception ; an error in diagnosis led to an operation after 
the aneurism had apparently undergone spontaneous cure. In Caldwell's the swelling 
was thought to be an abscess. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 470 

made. In default of such limited pressure, general compression of 
the swelling in the axilla seems to be the only resource short of opera- 
tion. The common treatment of ruptured artery, incision and double 
ligature of the vessel, was immediately resorted to in only two of these 
cases ; both were promptly fatal. Korte's result after lateral ligature 
of a small opening in the artery is not encouraging, although a number 
of successes after incised wounds have been reported. 

In the reduction of recent dislocations, these accidents show that 
abduction of the arm especially should be avoided, as also circumduc- 
tion, violent traction, and rough pressure in the axilla. Kocher's 
method by manipulation and mine by the unsupported weight of the 
dependent limb appear well adapted to avoid the danger. It is also to 
be remembered that the injury to the vessel may be caused by the 
dislocation itself, and its symptoms may be masked by the swelling 
commonly present during the first few days. 

In old dislocations the probability of the occurrence of the accident 
is increased by the more forcible measures usually necessary to break 
up the adhesions that bind the bones in their new relations ; and, 
while it may be proper in many cases to make the attempt to restore 
the limb to usefulness, the possibility creates another reason for 
abstention when the patient is old, the duration of the dislocation long, 
and the adhesions firm. Even a dislocated arm may be very useful, 
and the fatality of this accident, more than 70 per cent, of deaths, 
may well cause the surgeon to hesitate to incur the risk merely for the 
sake of ameliorating a condition which does not endanger life and is 
quite compatible with activity and usefulness. 

Injuries to Nerves. These also have been far more frequently 
observed at the shoulder than elsewhere, and there is the same diffi- 
culty in many of the recorded cases in determining whether the injury 
was caused by the dislocation or by the manoeuvres employed to 
effect a reduction. 

The injury may consist in direct compression of the nerve against 
the bone, as in attempted reduction by the method of the door or 
ladder or by the heel in the axilla, or in forcible elongation or com- 
plete rupture of the nerve by traction upon the limb, or such change 
in its position that the nerve is stretched around the head of the bone, 
or in avulsion of the nerve from the spinal cord. As the autopsies 
are few in number our knowledge of the lesions is mainly clinical. 
In a case quoted in the preceding section, one of rupture of the brachial 
artery near the elbow, the median nerve was also ruptured ; and this 
double injury has been several times encountered in compound dislo- 
cation of the elbow. 

In a case reported by Flaubert, 1 and mentioned above in the section 
on Emphysema, a dislocation of the left shoulder five weeks old in a 
very stout woman aged seventy years, reduction was accomplished 
with difficulty after prolonged traction upon the arm by eight assist- 
ants. Beside the emphysema extending over the neck and back, there 

1 Marchand : Loc. cit., pp. 25, t>7. 



480 DISLOCATIONS. 

were syncope lasting an hour, cloudiness of vision, paralysis of the 
right arm, and left hemiplegia with loss of sensibility in the left arm 
but with pain referred to it. Thirty-six hours later there was sharp 
pain in the back of the head and neck and in the ears ; pain also in 
the left thigh, in which sensation was better than in the right ; the 
left arm was insensitive, without pain, and motionless ; the right arm 
numb and somewhat weakened ; pulse rapid, skin warm. The next 
day the pupils were dilated and did not respond to light. On the sev- 
enteenth day the respiration was embarrassed, the skin hot, pulse 
rapid, prostration great ; and on the nineteenth day death. The 
autopsy showed the lower four pairs of the brachial plexus on the left 
side to have been torn away from the spinal cord ; the torn ends 
plainly showed the delicate filaments by which they took their origin, 
and the ganglions on the posterior roots could be distinguished. The 
first pair had suffered no injury. The spinal dura mater was of a dark 
brown-red color, and the cord, at the point where the nerves had been 
torn away, was changed into a reddish-brown pulp in which the gray 
and white substances seemed mingled. 

The two following cases recorded by Flaubert l bear a close resem- 
blance clinically to this one. 

In a man, fifty years old, with a dislocation of the shoulder dating 
from a fortnight before, traction by three assistants caused numbness 
and pain in the hand and wrist ; a second attempt, with six assistants, 
instantly caused numbness in the corresponding leg, and the reduction 
was abandoned. The following night there was sharp pain in the 
lower cervical vertebras, subsequently extending to the dorsal region. 
The arm remained almost completely paralyzed. 

A dislocation of the shoulder seven weeks old in a woman sixty-four 
years of age was reduced by traction made by five assistants. At the 
moment of reduction the patient felt a sort of rupture at the wrist, 
followed by a quivering that extended to the lower third of the arm 
and by complete hemiplegia and great diminution of sensation on the 
same side, especially in the arm. The lower limb regained its power, 
but the arm remained paralyzed and atrophied. 

In other cases the effects, as indicated by the symptoms, have been 
limited to the limb, arm or leg, or to portions of it. 

Erichsen 2 quotes from Billroth a case of dislocation of the shoulder 
of nine months' standing which had been accompanied by partial 
paralysis of the arm and some atrophy. The reduction was followed 
by total paralysis. Le Bret 3 reported one which occupies a position 
intermediate between this class and the preceding : a soldier dislocated 
his right shoulder ; reduction was immediately made by traction, and 
was followed by paralysis of motion in the entire arm, loss of sensa- 
tion below the elbow and on the right side of the neck, and by ptosis 
and dimness of vision on the same side. In most of the more recent 
recorded cases the history leaves it in doubt whether the paralysis was 

1 Quoted by Malgaigne : Loc. cit., pp. 158, 159. 

2 Erichsen : Surgery, Aru.ed., vol. i. p. 415. 

3 Le Bret : Soc. de Biologie, 1854, p. 119. Quoted by Weir Mitchell. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. A*> \ 

caused by the dislocation or by the reduction. In the older cases, 
in which the rough method of the door, ladder, or ambi was employed 
for reduction, there can be but little doubt that the paralysis was com- 
monly caused by the reduction. At the shoulder the nerve most 
frequently affected is the circumflex ; Marchand thinks this nerve is 
commonly injured by the dislocation ; the others by the reduction. 
Instances of injury in other dislocations than those of the shoulder are 
rare. Hutchinson 1 describes a case of isohiatic dislocation of the 
femur reduced by manipulation under ether, followed by complete 
anaesthesia of the limb below the knee except on the inner side of it 
and of the foot. 

Maclise 2 gives a plate of dislocation of the femur backward in which 
the sciatic nerve is stretched over the neck of the bone ; and he says : 
" In general (in dislocations into the sciatic notch) the great sciatic 
nerve is bent over the femur and put on the stretch." . . . "I 
have seen it so situated in regard to the head of the femur that the 
reduction could not possibly have been effected with safety to that 
nerve/' The plate apparently represents a dislocation produced upon 
the cadaver, and it seems probable that the text refers to dislocations 
similarly produced. I have known of only one clinical case in which 
such relations of the parts have been observed (Quain's). 

Fracture. Fracture of the dislocated bone during reduction has 
occurred in dislocations of the shoulder, elbow, and hip, and not only 
when great force has been employed, but also during comparatively 
gentle manipulations to flex, abduct, or rotate the limb. 

At the shoulder the recorded cases appear all to have been disloca- 
tions of long standing in elderly people, and in most the accident was 
caused by forcible rotation during traction. Of late years I have 
heard of several cases of fracture in comparatively recent dislocations 
caused by attempts to reduce by Kocher's method. The fracture is 
usually at or just below the surgical neck. 

Several authors assert that the ribs have been broken during reduc- 
tion by the pressure of a firm axillary pad used as a fulcrum, and also 
say that the lip of the glenoid cavity maybe broken during reduction. 
In Weir's case, quoted on page 462, the third, fourth, and fifth ribs 
were broken in the axillary line, apparently by pressure of the heel. 

At the elbow fracture of the olecranon has been frequently caused, 
either intentionally or by accident, in the reduction of old dislocations. 
There is but one recorded case of its fracture in a recent dislocation, 
and even in this there is some doubt whether the fracture had not taken 
place before the reduction was attempted. 3 

Markoe 4 mentions a case, apparently unique, of fracture of the 
humerus in an attempt to reduce an old dislocation of the elbow. 
"While making extension, and at the same time trying to flex the 
forearm on the arm, the humerus gave way, and a very oblique frac- 

1 Hutchinson: Medical Times and Gazette, 1866, i. p. 194. 

- Maclise: Dislocations and Fractures, Plate xw. Fig. 2. 

:! Daugier, in Malgaigne: Loc. cit., p. 146. 

4 Markoe: Diseases of the Bones, p. IS. 
31 



482 DISLOCATIONS. 

tare was found to have occurred about a hand's breath above the 
joint." 

I have seen one case of backward dislocation at the elbow in which 
a forcible change of the position from full extension to flexion at a 
right angle had broken off the trochlear portion of the humerus and 
displaced it forward and upward. 

In dislocations of the hip the femur has been broken, usually: at the 
neck, but once at least at the lower end of the shaft ; and it is asserted 
by some that the rim of the acetabulum also has been broken. The 
accident appears to have been due not to traction, but to efforts made 
by the hands of the surgeon to change the position of the limb, rota- 
tion or abduction. Although the force thus applied is slight compared 
with that developed by the use of pulleys, it must be remembered that 
its effect is greatly increased by the leverage of the limb. 

Inflammation, Suppuration, Gangrene. The inflammatory reaction 
induced by a dislocation is usually moderate, and rarely terminates in 
suppuration ; and when excessive reaction does follow the reduction of 
a recent dislocation, it is not always possible to determine whether the 
original traumatism or the reduction is responsible for it. In disloca- 
tions of long standing this difficulty does not exist, for the primary 
reaction has completely subsided, or, if persistent, has become moderate 
and chronic before the reduction is attempted, and its renewal or exacer- 
bation is plainly due to the interference. 

The inflammation may be due to the direct pressure of the apparatus 
used for making traction, or to laceration of the parts about the affected 
joint ; the latter is the more dangerous because of the probability that 
the inflammation and suppuration may extend to the cavity of the 
joint, but the former also has proved fatal. 

Of laceration of the parts about the affected joint the following case 
is an example. It was under the care of Malgaigne, is briefly referred 
to by him, 1 and is reported in full by Parmentier : 2 A man, thirty-four 
years old, with an intracoracoid dislocation of six months' standing. 
Three attempts to reduce were made, the traction in the last amounting 
to more than four hundred pounds, and the head of the bone being 
brought almost back to its place, but an attempt to force it into place 
by lateral traction with a bandage failed and even lacerated the skin 
on the posterior margin of the axilla. On the fifth day after the last 
attempt the patient complained of pain in the axilla, and the following 
day became delirious, and a large quantity of pus escaped through the 
laceration of the skin ; trismus and tetanus followed, and death two 
days later. 

The autopsy showed abscesses under and behind both pectoral mus- 
cles, in the substance of the coraco-brachialis and along its under sur- 
face, and communicating with the new articular cavity through a rent 
in its capsule. 

The following case, reported by Mr. Jonathan Hutchinson, 3 is even 
more striking. An elderly woman, drunk, was admitted with a dislo- 

1 Malgaigne : Loc. cit., p. 168. 2 Parmentier : Bull, de la Soc. Anatomique, 1852, p. 302. 
3 Hutchinson : Medical Times and Gazette, 1866, vol. i. p. 304. 



ACCIDENTS BY ATTEMPTS TO REDUCE A DISLOCATION. 183 

cation into the axilla; an attempt to reduce failed. The next day she 
said the shoulder had been dislocated for several years, but she was not 
believed, and reduction was again attempted with the aid of chloro- 
form by moderate manual traction directly outward and the knee in 
the axilla as a fulcrum ; the attempt was continued for ten minutes. 
Great inflammation followed, the joint suppurated, and the patient 
died. The autopsy showed a new articular cavity formed below and 
in front of the glenoid cavity. The soft tissues of the joint were 
wholly destroyed by suppuration, and every trace of cartilage removed. 

An experience of Broca's shows that an unfortunate, even fatal, 
result may follow an apparently judicious and moderate attempt at 
reduction. 

The patient, 1 a coachman, thirty-nine years old, entered the hospital 
for treatment six months after he had dislocated his left hip. Trac- 
tion to the amount of more than five hundred pounds was made with 
Mathieu's apparatus without success, and the attempt was not repeated. 
No ill result appearing, the patient was discharged at the end of a week. 
A fortnight later he was admitted to another hospital with considerable 
swelling of the hip and peritonitis, and died on the following day. 
The autopsy showed a collection of pus occupying the old and new 
articular cavities, filling the external iliac fossa, infiltrating the gluteus 
medius, and in contact with the entire surface of the internal and exter- 
nal obturators and with the obturator foramen ; also a generalized peri- 
tonitis, much more marked in the true pelvis than elsewhere. The 
course of the lesion was thought to have been : inflammation of the 
new joint, extension to the old one, then to the obturator internus, and 
finally to the peritoneum. It was thought probable that the patient 
had resumed work immediately after leaving the hospital, and that this 
untimely use of the limb had provoked the suppuration. 

In a few recorded cases the inflammatory reaction was so severe that 
the limb, or the affected segment thereof, became gangrenous. Dupuy- 
tren 2 reported a case in which, after reduction of a dislocation of the 
thumb by long and violent efforts, the thumb became gangrenous and 
separated at the metacarpophalangeal joint. 

These cases are to be distinguished from those in which gangrene 
has been caused by injury to the vessels or nerves, as in La Motte's 
case, 3 Weir's first case quoted in Chapter XXXIII. , page 468, and 
probably in Delagarde's, 4 in which, after reduction of an old dislocation 
of the shoulder, abscesses and points of gangrene formed in the limb 
and rendered amputation at the shoulder necessary. 

Persistent oedema of the limb, a condition resembling elephantiasis, 
has been observed in a few cases in which unsuccessful attempts had 
been made to reduce old dislocations, apparently the result of inter- 
ference with the venous flow. In a case of Malgaigne's, quoted by 
Velpeau, 5 the cedema of the arm disappeared simultaneously with the 
development of numerous varicose veins in the arm and shoulder. 

1 Reported by Tillaux in Hull, de la Soc. do Chir., 1868, vol. iw p. 266, 

2 Dupnytren : Quoted by Marchand, loc. cit., p. 129. 

3 La Motto: Traite" do Chirurgie, vol. iv. p. 343. 
'Delagarde: St. Bartholomew's Hospital Reports, vol. iv. p. 89. 
5 Marc-band: Loc. cit., p. 131. 



484 DISLOCATIONS. 

Syncope and Sudden or Early Death ; Fat Embolism. Beside 
the numerous cases already quoted in this chapter which show the 
dangers to the life of the patient that may arise in the course of an 
attempt to reduce a recent or an old dislocation, there are still others 
which indicate that life may be seriously threatened, or even destroyed, 
by other accidents or complications than the rupture of important 
vessels or nerves or excessive reaction and suppuration. In some of 
the fatal cases the failure to make an autopsy leaves the cause of death 
obscure, but the symptoms point to rupture of a vessel as a possible 
cause. 

E. Boeckel l has reported a case the autopsy of which suggests another 
explanation, not only of some of the deaths by syncope, but also of 
some attributed to the anaesthetic. 

The patient was a man fifty years of age, with a recent ilio-pubic 
dislocation, who was brought to the hospital after an unsuccessful 
attempt to reduce. Chloroform was given and reduction made in seven 
minutes ; the patient grew pale, his respiration weakened and promptly 
stopped. The autopsy showed the heart to be atrophied, both pulmon- 
ary arteries plugged by non-adherent clots, rounded like emboli, in the 
medium-sized branches and those of the third and fourth order, and 
also fat embolism of the lungs very widespread and intense. The iliac 
and femoral veins were free, but there was a thrombus in the popliteal 
vein from which it was thought those in the pulmonary arteries had 
been broken off. 

Before the use of anaesthetics, in the times when muscular resolution 
was sought to be obtained by measures which depressed and weakened 
the patient, and when the efforts to reduce were made with great vio- 
lence and sometimes prolonged for hours, exhaustion of the patient 
habitually followed, and death was sometimes the consequence. 

Death by the action of an anwsthetic, especially chloroform, is 
thought to occur in a larger proportion of cases of reduction of dislo- 
cation than of other operations, but no satisfactory explanation of the 
greater risk, if it actually exists, has been given. Of 134 cases of 
death by an anaesthetic collected by Marchand, in 17 the operation was 
the reduction of a dislocation; of these 11 were of the shoulder, 3 of 
the hip, and 1 each of the knee, elbow, and thumb. 

1 E. Boeckel: Mort subite par embolies pulmonaires, simulant la mortpar le chloroform 
apres reduction d'une luxation de la cuisse. Kev. des Sciences Med., Oct. 15, 1881, p. 637. 



CHAPTER XXXV. 

CONGENITAL 1 DISLOCATIONS. 

Under the term non-traumatic may be included all dislocations 
which exist at birth {congenital), although it is claimed that some of 
them are due to violence inflicted upon the foetus in utero, or even 
during delivery, and those which appear subsequent to birth as the 
result of non-traumatic changes in one or more of the constituent parts 
of the joint (" spontaneous/' " symptomatic/' " inflammatory/' 
"paralytic," "myopathic," "chronic," "tardy," "dislocation by 
distention," " by relaxation," " by destruction," " by deformity "), 
and those which may be reproduced at will by the individual, " vol- 
untary." 

The existence of dislocations (at least of the hip) in the new-born 
child, and their non-traumatic character, have been recognized since 
the earliest times, but the accurate study of the subject may be said to 
have begun in 1818, with Schreger, who examined post mortem two 
specimens in a girl two and a half years old and a woman of forty- 
eight. A few years later, 1826, Dupuytren brought the subject before 
the Acad6mie des Sciences, and called attention especially to the facts 
that the affection was often inherited, and often bilateral. Since then 
the subject of congenital dislocation of the hip has been actively studied 
by many, and the similar but much rarer affections of other joints have 
received due attention. 

Statistics. Dislocations have been observed at birth in many joints, 
but not only do those of the hip far exceed all others in number, but 
the latter are actually, as well as relatively, so rare that their statistics 
have not much value. Next to that of the hip the most common dis- 
location is apparently of the shoulder, and then that of the head of the 
radius. Kronlein says that the records of Von Langenbeok's Poly- 
clinic show 90 congenital dislocations of the hip, 5 of the shoulder. '2 
of the head of the radius, and 1 of the knee. It is not exceptional to 
find several dislocations present in an individual, or one or more dislo- 
cations associated with such congenital defects as spina bifida, club- 
foot, ventral hernia, encephalocele, and exstrophy of the bladder. 

As will appear in studying the etiology of this affection, the statistics 
of congenital dislocation of the hip include cases widely different in 
their origin, and even some which are acquired and not congenita], 
that is, some which have been produced during the first few months of 
life, perhaps before the patient began to walk, by the unopposed action 
of certain groups of muscles after paralysis of others. It seems proh- 

1 The use of the term congenital to classify certain dislocations is objectionable for 
several reasons, which will appear in the course of the discussion of the subject. It in- 
cludes forms that radically differ in their etiology and pathology, but as these forms can- 
not well be distinguished from one another during life, a classification based upon other 
points cannot be realized in practice, but must be confined to the dead-house and museum. 



486 



DISLOCATIONS. 



able, however, that the error thus arising is not a large one, but still, 
for this and for other reasons, I shall here quote only the more recent 
statistics, believing them to be the most nearly correct. These are 
Drachniann's, 1 Pravaz's (quoted by Kronlein), and Kronlein's. 2 

Congenital Dislocations. 





Period. 


Cases. 


Male. 


Female. 


Single. 


? 






Left. 


Right. 




Drachmann . 
Pravaz .... 
Kronlein 


1865-1880 
1863-1878 
1875-1880 


77 

107 

90 


10 
11 
14 


67 
96 
76 


24 
27 
32 


24 
29 
22 


5 


29 
51 
31 


Total 




274 


35 


239 


83 


75 


5 


111 









PrahPs 3 are not given in sufficient detail to be included in the table ; 
they comprise 18 cases; 3 were males, 15 females, making with those 
in the table a total of 292, of w r hich 38 were males, 13 per cent., and 
254 females, 87 per cent. Angot 4 says that of about 20 cases observed 
by him at the Hopital des Enfants malades in 1882, all were girls. 
Of 11 cases of congenital dislocation of the knee collected by Hibon, 5 
7 were girls, 3 boys, and in 1 the sex was not recorded ; of these, 3, 
1 girl and 2 boys, were stillborn, and presented other very marked 
deformities. 

Etiology. 

The discussion of this branch of the subject, which was taken up 
with much interest after the publication of Dupuytren's memoir, was 
not fruitful of positive results because of the lack of anatomical mate- 
rial and minute examination, and of failure distinctly to discriminate 
between different forms and between the original bony defects and the 
changes produced by the long use of the deformed limb. Since the 
affection is one which often escapes recognition until the child begins to 
walk, it was sometimes confounded with dislocations resulting from 
infantile paralysis, and as it is one which does not destroy life the op- 
portunities for direct anatomical investigation were almost entirely re- 
stricted to two classes of cases, the stillborn and those that died shortly 
after birth in consequence of other important congenital defects, and 
those in which the original changes had been masked or supplemented 
by subsequent ones produced by the further displacement of the head 
of the femur and its abnormal relations to the adjoining parts. In the 
former, incorrect inferences were drawn from the associated defects, 
as when the irritation of an over-full urinary bladder or the separa- 
tion of the symphysis pubis was deemed the immediate cause of 

1 Drachmann : Schmidt's Jahrbiich., 1881, vol. clxi. p. 170. 

2 Kronlein : Deutsche Chirurgie, Lief. 26, p. 82. 

3 Prahl : Inaug. Dis. Breslau, 1880. Abst. in Centralblatt fur Chir., 1881, p. 57. 

4 Angot: Luxations congenitalesde la hanche. These de Paris, 1883, p. 11. 

5 Hibon : Luxations congenitales du tibia en avant. These de Paris, 1881, p. 7. 



CONGENITAL DISLOCATIONS. 18 7 

the arrest of development of the acetabulum ; and in the latter the 
attention was led far astray by prominent changes in the bones. The 
history of the theories advanced has not only an historical value, but it 
serves also to indicate certain varieties and prominent features of the 
affection, and therefore I append the following resume made by Krori- 
lein. It must be remembered that most of the theories deal exclus- 
ively with dislocations of the hip. 

1. The so-called congenital dislocation is traumatic, and arises : 

a, through external violence acting upon the foetus in utero, or through 

the action of the muscles of the foetus itself. Hippocrates and 
the early writers held that mechanical injuries of the belly of 
the mother could produce dislocation in the foetus. Cruveilhier 
did not entirely reject this theory in some cases. Chatelain, 
Kleeberg, Zielewicz, even specify in their three cases the injury, 
a fall in the seventh month, which, in their opinion, had caused 
the dislocation. Chaussier claims even that a dislocation can 
be caused by the contraction of the muscles of the foetus, and 
narrates in support the case of a young woman who, during the 
ninth month of pregnancy, felt on three occasions such violent 
movements of the child that she almost became unconscious. 
When delivery took place at term, the child had a complete 
dislocation of the left forearm. 

b, during delivery. 

Capuron (1834) held that some congenital dislocations of the 
hip had been produced during delivery, by traction with the 
finger on the groin in breech-presentations. 

2. Congenital dislocation (of the hip) is a spontaneous dislocation., and 
is occasioned : 

a, by softening and laxity of the ligamentous portion of the joint (Sedil- 

lot, 1836). This opinion was held in part by Stromeyer (1840). 

b, by fatal hydrarthrosis (Parise, 1842) or other joint affections, such 

as fungous synovitis with effusion (Verneuil and Broca), or 
caries and destruction of the capsule (Morel Lavallee, Albers, 
Von Ammon). 

3. Congenital dislocation (of the hip) is due to the peculiar position of 
the lower limbs of the fcetus in utero. 

a, it is possible that in the strongly flexed position of the Jiip the press- 

ure of the head of the femur upon the posterior or lower por- 
tions of the capsule may, when the latter is abnormally weak 
cause dislocation (Dupuytren, 1826). 

b, congenital dislocation of the hip is due to abnormal adduction of 

the thigh in utero, to a compressed position of the foetus duo to 
deficiency in the amount of the amniotic liquid (Roser, 1864), 

4. Congenital dislocation of the hip , like most congenital deformities 
of the joints, such as club-foot, wry neck, and spinal curvature, is tin 
residt of primary muscular contraction, which is itself to be regarded as 
the result of an affection of the central nervous system (J. Gu€rin, 
1840, and, following him, Chaussier, Melicher, Mercer-Adam, Carno- 
chan, Erichsen, and others). 

5. Congenital dislocation of the hip is often only the last stagi 



488 DISLOCATIONS. 

paralysis and consequent atrophy of the pelvic-trochanteric muscles. This 
foetal paralysis leads gradually to relaxation of the ligaments, and this, 
often only after the lapse of time, and especially after the children have 
begun to walk, and by the action of the weight of the body, to dislo- 
cation (Verneuil, 1866). This theory has recently (1878) been brought 
forward again by some of Verneuil's pupils (Reclus, Dalby), and 
extended to congenital dislocations of the humerus (Kirrnisson), 

(Kronlein in this fails accurately to define the position of the sup- 
porters of this theory. Their contention is not so much that congenital 
dislocations are thus produced, but rather that some so-called congen- 
ital dislocations originate after birth in a paralysis, and are mistakenly 
thought to have been congenital. Reclus 1 formulates his conclusions 
as follows : 

a. From the group of so-called congenital dislocations paralytic dis- 
locations must henceforth be withdrawn. 

b. These dislocations follow " amyotrophies," and may appear at 
any age, although they have rarely been seen except in infancy. 

c. For their production two conditions are necessary — atrophy of a 
muscular group ; integrity of its antagonists. 

d. At the hip the iliac dislocation is the most common. It is due 
to the contraction of the adductors, which is unopposed because of the 
atrophy of the gluteal and pelvi-trochanteric muscles.) 

6. Congenital dislocation of the hip is due in most cases — and these 
should be regarded as typical — to a defect of formation or development, 
which prevents the joint from assuming the normal shape. This very 
generally held theory was presented by Palletta, and then taken up 
and specially developed by Schreger, Dupuytren, Breschet, Von Am- 
nion, and others. 

Schreger emphasizes the fact that so-called congenital defects are not 
produced by an abnormal change in pre-existing, normally formed parts, 
but are due to defective formation or arrest of development, and that 
is especially true of congenital dislocations of the hip. Dupuytren and 
Breschet suggest a delayed development of the three pelvic bones form- 
ing the acetabulum. Von Amnion, 2 in his remarkable work, expresses 
himself very clearly concerning congenital dislocations, which he terms 
dysarthroses congenita?. "Even if their external appearance," he 
says, "corresponds somewhat with that of dislocations acquired after 
birth, yet in their method of formation they differ essentially from 
them, and they also have only the slightest resemblance to those sec- 
ondary dislocations that follow joint disease. ... In many cases 
there is in part the greatest certainty, and in part the greatest proba- 
bility, that the affection depends upon an arrest of the constituent parts 
of the joint at an earlier fcetal stage of development. According to 
him, a congenital dislocation is an arrest of development. The ace- 
tabulum does not develop into the usual, symmetrically rounded, deep 
socket, but retains its earlier saucer shape ; while the head of the femur, 
continuing to grow, becomes too large for the small acetabulum, and 
no longer suitable to lodge in it. 

1 Eeclus : Revue Mensuelle de Med. et Chirurgie, 1878, p. 88. 

2 Von Amnion : Die angeborenen chirurgischen Krankheiten des Menschen, 1842, p. 9. 



CONGENITA L UISL OCA TIONS. 480 

Von Amnion recognized not only this typical form of congenital 
dislocation but also the other varieties that had been described by other 
authors, and quoted cases and reproduced drawings in illustration of 
them. So far as the typical form is concerned, but little has been 
added since his time to our knowledge of its pathogeny, and that little 
is contained in a paper published by Grawitz 1 in 1878, who, by micro- 
scopical examination of twelve specimens of congenital dislocation in 
seven new-born children, showed that the arrest of development con- 
sisted in a failure of the Y-cartilage of the acetabulum to carry on the 
grow T th of one or all of the three segments of the os innominatum. 
He found, in his first case, for example, the acetabulum only as large 
as that of a foetus of about the fifth month, and the Y-cartilage broader 
than usual because of diminished ossification of the three adjoining 
bones, the pubis, ischium, and ilium. The cartilage was hyaline and 
vascularized, and with normal, elongated cells containing one, two, or 
three nuclei. On comparison with sections of a normal pelvis of the 
same size, a striking difference appeared at the junction of the bone 
and cartilage. The formative zone in all three epiphyses was very 
imperfect, its cells scanty and widely separated, and the zone of cells 
arranged above one another in rows adjoining the line of ossification 
was not one-third as wide as it normally is, and the arrangement of its 
cells was irregular and broken. In some of the cases the Y-cartilage 
was centrally interrupted by an interposed wedge of embryonal adipose 
tissue. On the other hand, the appearances in the femur were those of 
normal growth, except in one case. In no case was there premature 
ossification of the Y-cartilage, such as had been alleged shortly before 
by Dollinger 2 in explanation of the same affection. 

The conclusion, I think, cannot be avoided that wdiile in a limited 
number of cases dislocations existing at birth, especially in joints other 
than the hip, may have been caused by traumatism, abnormal position 
of the limb, or paralysis in the manner alleged by various writers, yet 
in the great majority of congenital dislocations of the hip the cause is 
to be found exclusively in arrest of development of the acetabulum by 
deficient action or vitality of the cells of the Y-cartilage. And to the 
testimony in support of this opinion furnished by anatomical examina- 
tion of specimens may be added that drawn from clinical observation, 
such as the coexistence of other deformities due to arrest of develop- 
ment, the frequency of double and multiple dislocations, the inherited 
tendency to the affection, and its great predominance in females. 

Many of the congenital dislocations of other joints than the hip must 
also be regarded as due to defective formation of the corresponding 
bones, but the defect apparently is rather a malformation than the 
result of an arrest of the development of one of the bones constituting 
the joint. At the elbow, in dislocation of the head of the radius, this 
bone is sometimes found relatively, and even actually, longer than the 
ulna. In a specimen taken from an adult, pictured by Humphry 8 
(Fig. 266), of dislocation of the head of the radius forward and 

1 Grawitz: Virchow's Archiv, 1878, vol. lxxiv. p. 1. 

2 Dollinger: Arch, far klin. Chirurgie, 1S77, vol. xx. p. 622 

3 Humphry: Medico-Chirurgical Transactions, ya>1. xlv. p. 296. 



490 DISLOCA TIONS. 

upward, there was anchylosis of the joint between the ulna and 
humerus, and the lower third of the ulna of the other arm was lacking. 

Fig. 266. 




Congenital dislocation of the head of the radius upward and forward, with exaggerated 

growth in length. 

In some dislocations of the knee characterized by hyper-extension of 
the leg upon the thigh the cause appears to have been muscular con- 
traction. 

Of the other etiological varieties that have been asserted to exist, 
one at least seems to have been proved by direct examination to exist, 
that in which the dislocation follows distention of the capsule and 
ligaments by dropsy of the joint during intra-uterine life. 

Pathology. 

The opportunities for studying the pathology of congenital disloca- 
tions other than those of the hip have been so very rare, and the study 
of those that exist has been made so uncertain by the doubtfulness of 
the diagnosis in some and the difficulty in distinguishing between 
primary and later changes in others, that but little can be positively 
said concerning them. In studying specimens of dislocation of the 
hip it is necessary, as Gurlt pointed out, to distinguish between those 
obtained from very young children who have never walked, those 
from older children whose growth was not' completed, and those from 
adults. 

Hip. The common form is dislocation upon the dorsum of the ilium ; 
the only exceptions, and they are extremely rare, are upon the pubis 
and into the obturator foramen. 

In the new-born child with a dislocation the acetabulum is smaller 
and flatter than normal, and is continuous by its flattened posterior 
border with another articular surface or new acetabulum lying above 
and behind the original one. Usually, too, the head of the femur is 
smaller than normal, although still too large for the acetabulum, and 
the neck short or almost absent ; sometimes the head and neck together 
have a conical pointed form. The ligamentum teres is long and flat- 
tened, the capsule is complete, and embraces both the old and the new 
acetabulum. The microscopical changes have been described above. 

The mechanism of the alteration seems plain ; as the femur and its 
socket originally are developed out of one continuous strip of tissue, they 
are at first in normal relations to each other, but when the development 
of the acetabulum goes on more slowly and imperfectly than that of 
the head of the femur the latter becomes relatively too large, and being 
no longer firmly held in place it is gradually drawn backward and 



PATHOLOGY OF CONGENITAL DISLOCATIONS. 



191 



upward by the continuous action of the attached muscles, the corre- 
sponding edge of the capsule is pressed away from the cotyloid border, 
and a new articular* surface is formed at the point where the head of 



Fig. 267. 




Innominate bono and femur from a case of congenital dislocation of the hip, after operation 
for formation of a new acetabulum. (Bradford.) 

the femur comes to rest. Meanwhile, the defective development of the 
original acetabulum persists, and its variation from the normal is prob- 
ably still further increased by the absence from it of the femur. The 
remaining bones and the muscles, not being put to sufficient use to feel 
the effect of the changed relations in the joint, sutler do change unless 
involved in some associated detect of development. 



492 DISLOCATIONS. 

But as soon as the child begins to walk this change in the relations 
of the bones and muscles to each other makes itself felt, and, as the 
local developmental weakness persists, two factors are now at work to 
remove the condition of the parts still further from the normal. The 
acetabulum by its continued failure to share equally in the growth of 
the pelvis, becomes relatively smaller and more deformed, the head of 
the femur is removed still further from it, and becomes deformed in 
consequence of its irregular bearings upon the surface of the ilium ; 
the ligamentum teres becomes longer, flatter, and thinner, and the cap- 
sule thick and strong, and its cavity commonly larger than usual. As 
the individual advances in life, and after puberty has been reached, the 
ascent of the femur is finally arrested, partly by the formation of a 
socket, and partly by the resistance of the capsule and the muscles. 
The elements of support then resemble in a measure those sometimes 
found with ununited fracture of the neck of the femur, and the pelvis, 
instead of resting directly upon the femur, is suspended from it by the 
capsule, ligaments, some of the pelvi-trochanteric muscles, and even 
by the psoas-iliacus, the tendon of which, instead of passing down- 
ward, curves around the brim of the pelvis, and passes upward, out- 
ward, and backward to the lesser trochanter, which is now at a higher 
level than the acetabulum. 

The head of the femur may be separated from the ilium by the inter- 
posed capsule, so that the support is entirely by suspension, and there 
is no real joint, one in which bony surfaces covered with cartilage play 
upon each other ; or the upper and posterior attachment of the capsule 
may still be found above the head of the femur, upon an overgrowth 
of bone springing from the ilium and forming the upper part of a new 
socket, the remainder of which is constituted by the body of the ilium. 
The latter bone sometimes shows at this point an overgrowth of bone, 
and sometimes a depression with a corresponding thickening on the 
opposite, inner surface. In the former of these two last-named con- 
ditions, it seems probable that the capsule has been for a time inter- 
posed between the femur and the ilium, and has finally disappeared at 
this point under pressure, the irritation of which has caused the out- 
growth of bone before its periosteum has in turn disappeared ; in the 
latter, it is probable that the attachment of the capsule has been pushed 
back step by step, leaving a bare surface of bone which has worn 
away under the pressure of the femur, or by absorption ; while the asso- 
ciated irritation has led to a conservative thickening on its other side. 
The communication between the cavity of the capsule about the head 
and the acetabulum is through a narrowed portion, so that the whole 
is like an hour-glass. The old acetabulum is narrow and elongated, 
running upward and backward ; the ligamentum teres perhaps destroyed 
by over-stretching. 

The entire pelvis is also changed in shape by the abnormal direction 
of the pressure to which it is subjected in walking. If the dislocation 
is unilateral, the crest of the ilium on the corresponding side is carried 
inward, and the tuberosity of the ischium outward, the horizontal 
branch of the pubis is elongated, and its direction from the symphysis 
is more upward and backward ; the anterior superior spine of the ilium 



PLATE L 




Fig. 1.— Congenital Dislocation of Hip; girl, three years old. 




Fig. 2.— Dislocation of Semilunar Bone 



PLATE L; 




Congenital Dislocation of the Hip. 



SYMPTOMS AND DIAGNOSIS OF CONGENITAL DISLOCATIONS. 493 

is displaced inward and backward, and, in short, the entire bone under- 
goes a change in shape which carries its centre upward and backward, 
and makes its lateral surface more vertical. 

If the dislocation is double, the same changes are found on both 
sides, and the sacrum is more sharply curved. 

Congenital dislocation of the shoulder may be either subcoracoid, sub- 
acromial, or subspinous. R. W. Smith, 1 who was the first to describe 
them, gives examples and plates of the first two forms. He found the 
original glenoid cavity lacking or rudimentary, and the new one well 
developed either immediately under the coracoid process or on the outer 
side of the scapula below the acromion. Most of the cases described 
as such appear to be traumatic (during delivery) or paralytic. (See 
Chapter XLIV.) 

At the elbow the head of the radius may be displaced upward along 
the anterior surface of the humerus, or backward, or inward so as 
partly to overlap the coronoid process of the ulna. 

Symptoms and Diagnosis. 

The symptoms of congenital dislocations differ very widely from 
those of the traumatic variety, and not only by the absence of symp- 
toms peculiar to a traumatism, but also in the signs recognizable by 
palpation, and in the posture and mobility of the limb. In general 
terms, the dislocation is to be recognized by an examination which 
determines the abnormal position and altered shape of the correspond- 
ing ends of the bones and the range of motion, and by consideration of 
the history of the case. 

In dislocations of the hip the changes are very likely to pass unno- 
ticed until after the child has begun to walk, because during this first 
period they are usually too slight to attract attention, and because an 
examination for their detection is not likely to be made unless it is 
suggested by some special reason, such as coexisting malformations, 
or the history of similar defects in other members of the family. Even 
after the child has begun to walk, the defect may long remain unrecog- 
nized if both hips are affected, because, the deformity of the regions 
and the shortening of the limbs being symmetrical, they do not attract 
much attention. Nevertheless, the changes are so characteristic that 
when an examination is made the diagnosis cannot well remain in doubt. 

When the dislocation is unilateral and of the common dorsal variety, 
the patient limps because of the shortening of the affected limb ; and 
for the same reason the spine shows a lateral curvature, which can be 
removed by supporting the foot at the proper height. Because of the 
passage of the head of the femur backward and upward upon the 
ilium, the pelvis is tilted so that its upper portion is directed forward, 
and a marked anterior curvature of the lower portion of the spinal 
column is produced, which disappears when the patient is recumbent. 

Inspection and manipulation reveal the ascent of the trochanter, ami 
the head of the femur may sometimes be distinctly recognized. The 
shortening may be slight, moderate, or very great, and can sometimes 
1 R. W. Smith: Dublin Medical Journal, L839, vol. xv. p. 261. 



494 



DISLOCATIONS. 



be notably increased by pressing the limb upward. Usually the glu- 
teal muscles and those of the thigh are less developed than those of 
the opposite limb. The movements of the joint are even more free 
than normal, except perhaps in abduction, but when voluntarily per- 
formed they are more or less lacking in precision and firmness. 



Fig. 268. 






Double congenital dislocation of the hip. 



When the dislocation is bilateral, the patient walks, not with a limp, 
but with a peculiar characteristic waddle, which sometimes amounts to 
a double limp and makes progression difficult and uncertain. The 
upper part of the pelvis is sharply inclined forward, producing the 
same lordosis that is found in unilateral dislocation, but without the 
lateral curvature unless there is a difference in the amount of the defect 



TREATMENT OF CONGENITAL DISLOCATIONS. 495 

on the two sides. The arms appear unusually long, and are sometimes 
exceptionally muscular. Often the deformity increases with time, and 
the patient has repeated attacks of pain ; in some the flexion and adduc- 
tion are such that the disability is great. 

At other joints, such as the shoulder, elbow, and knee, the position 
of the bones and the changes in their shape can usually be easily made 
out. 

Prognosis. 

The prognosis in all dislocations, except that of forward dislocation 
(hyper-extension) at the knee, is unfavorable, so far as reduction is 
concerned. 

Treatment. 

Until within a few years treatment of congenital dislocations of the 
hip was practically limited to palliative measures, such as a thick sole 
in unilateral cases and girdles and corsets which mechanically opposed 
the tilting of the pelvis and the ascent of the trochanter under pressure, 
and to continuous traction maintained for months and followed by the 
use of traction-splints in both unilateral and bilateral cases. By these 
means the functional condition in many cases appears to have been 
greatly improved, and much of the improvement to have been main- 
tained. 

Lannelongue l sought by periosteal irritation to create a buttress of 
bone upon the ilium which would prevent the ascent of the femur after 
it had been brought down by traction. He produced this by injection 
through a hypodermic needle of twenty drops of a 10 per cent, solution 
of chloride of zinc at several points in the periosteum close above the 
head of the femur. 

Between 1890 and 1900 much attention was given to operative reduc- 
tion, or fixation, with the formation of a new acetabulum or enlarge- 
ment of the existing one. Since then this has largely given place to the 
so-called " bloodless operation " of which Lorenz is so well known an 
exponent. The literature of the subject is abundant ; the reader may 
advantageously consult articles by Dr. E. H. Bradford and Dr. T. H. 
Myers in the Annals of Surgery, August, 1894, and by Warbasse in 
the same, June, 1895. 

The earlier operative methods exposed the capsule by a lateral 
(Hoffa) or anterior (Lorenz) incision ; then the muscles were separated 
from the great trochanter, the flexors of the leg divided subcutaneously 
near the tuber ischii, the abductors near the pubis, the tensor vaginae 
femoris by open incision, and the rectus femoris through the first 
incision. The capsule was opened, and generally detached freely from 
the femur, the head turned out, and the acetabulum enlarged, or a new 
one made, by chiselling. 

The mortality of the operation was quite serious, and Lorenz 2 lias 
sought to do away with the division of the muscles. In children not 

1 Lannelongue: La Semaine Med., December 30, 1891, 

2 Lorenz: Volkmann's klin. Vortriige, 1895, No. 117, and Warbasse. in Annals of Sur- 
gery, June, 1895. 



496 DISLOCA TIONS. 

over five years old, when the femur can be drawn well down, he makes 
a three-inch incision downward and outward from the spine of the 
ilium, divides the fascia lata along it and also backward, divides 
the capsule in front, deepens the acetabulum, and puts the head of the 
femur in place. In children between six and eight years, when the 
femur cannot be brought fully down, he exposes the capsule in the 
same manner while strong traction is made in slight abduction against 
counter-traction by a perineal band, and after division of the capsule 
continuous traction until the head is brought down. In cases over 
nine years of age, with marked shortening and slight mobility down- 
ward, preliminary traction by about thirty pounds is made for a fort- 
night ; then continuous forcible traction is made during the operation, 
and the capsule is divided along the long axis of the neck and trans- 
versely near the ilium. It is important to make a deep excavation 
with a sharp upper margin for the new acetabulum. The limb is fixed 
in slight abduction for a month, and then massage and passive motion 
are begun. 

Myers recommends for old, deformed, or painful cases Kirmisson's 
subtrochanteric osteotomy, or HofiVs new operation of removal of the 
head and neck and of the posterior portion of the capsule, the limb 
being then dressed in abduction to insure close contact between the 
trochanter and ilium. 

The " bloodless method " (Paci and Lorenz) consists in bringing the 
head opposite the acetabulum by forcible extension and abduction of the 
thigh and retaining it there for several weeks by a plaster spica. For 
the details the reader may consult among many others an article in 
the K Y. Med. Journal, Dec. 6, 1902, p. 970. " It is undisputed that 
many excellent functional results have been obtained by this means, 
although the anatomical conditions remain very different from the 
normal. 1 Joachimsthal 2 showed a series of skiagrams taken one or 
two years after reduction which indicated that the rim of the acetabulum 
and the head and neck of the femur had notably increased in size. 

Congenital dislocations of other joints, except the knee, have rarely 
received any treatment. A few backward dislocations of the shoulder 
have been reduced by open operation, not a difficult task in a case of 
my own, for the glenoid fossa was well formed and contained within 
the capsule of the existing joint. (See Chapter XLIV.) 

In dislocations of the tibia forward, with extreme hyper-extension 
of the knee, a complete cure can usually be effected by forcible straight- 
ening of the limb and retention for a short time by splints. 

1 Schede: Central blatt fur Chirurgie, 1900, p. 740. 

2 Joachimsthal : Beilage zurn Centralblatt fur Chirurgie, 1904, p. 164. 



CHAPTER XXXVI. 

SPONTANEOUS DISLOCATIONS. 

These are dislocations which have occurred without the intervention 
of a recognizable traumatism. It is generally held that some of the 
constituent parts of the joint must have previously been so altered by 
disease as to facilitate the occurrence ; but while this preliminary change 
does doubtless occur in the great majority of cases, yet there is reason 
to think that spontaneous dislocation may take place without it, through 
the continuous action of the muscles, when the limb has been long kept 
in a favorable position. Roser 1 says he has seen, in three cases, spon- 
taneous dislocation of the hip produced by the reflex muscular contrac- 
tions excited by pressure on the anterior portion of the spinal cord in 
patients affected with kyphosis and consequent paralysis. The dislo- 
cations occurred slowly, without pain or swelling of the region, and 
without a sign of coxitis. 

The term " spontaneous," although not entirely free from objection, 
is in general use, and is usually preferred to others that have been 
proposed, such as pathological, symptomatic, inflammatory, and consecu- 
tive or secondary. Yolkmann 2 has classified them according to the 
primary changes which precede and facilitate their occurrence, as dis- 
locations, 1st, by distention; 2d, by destruction; 3d, by deformity; 
including in the first those cases in which the joint has become loose 
through distention of its capsule and ligaments by an effusion within 
it, as in the eruptive fevers, rheumatic fever, pyaemia, and the puer- 
peral state ; in the second those in which the shape of the articular end 
of the bone has been changed by caries, as in hip-joint disease ; and in 
the third those in which the shape has been changed by non-suppura- 
tive disease, as in arthritis deformans. To these may be added a 4th 
class, seen mainly in adolescents, in which the shape or growth of the 
bone has been so modified by the effects of pressure, muscular effort, 
or gravity that a permanent displacement takes place ; and a 5th, 
" paralytic " or " myopathic," in which the dislocation is made pos- 
sible by paralysis of some or all of the articular muscles, and is some- 
times effected by the contraction of those which have not been paralyzed. 

Although the propriety of applying the term dislocation to a change 
in the relations of two bones whose corresponding articular portions 
have already been destroyed has been questioned, and although the 
change of place does not come within the definition of dislocation pre- 
viously given, and although the condition has but little in common 
with traumatic dislocations, either in symptoms or in treatment, yet 
the term has been almost universally accepted and retained in prefer- 
ence to the proposed substitutes. 

1 Roser: Centralblatt f. Chirurgie, 1885, p. 569. 

2 Volkniami : Pitha and Billroth's Chirurgie, vol. ii. part ii. p. 658. 

32 i:>: 



498 D ISLOCA TIONS. 

In all these varieties the immediate cause of the dislocation is the 
action of gravity or muscular contraction. 

Dislocations by Distention (Volkmann). Concerning the pathology 
of this class but little is known by direct examination, because of the 
lack of autopsies, but the clinical history is well established. The 
joint by far the most frequently involved is the hip ; a few cases have 
been observed at the shoulder and knee. In the most common form 
the course of the symptoms is a follows : ] A patient is attacked by 
febrile articular rheumatism or acute mono-articular arthritis; the pain 
is great, the limb assumes a faulty position ; after a few days the pain 
suddenly ceases, and on examination the region of the affected joint is 
found to present a deformity similar to that which characterizes a trau- 
matic dislocation. If the condition is left without treatment, the 
inflammation comes to an end without leaving either osteitis or suppu- 
ration, but with persisting deformity ; if, on the other hand, the dislo- 
cation is reduced, the deformity is thereby entirely removed, and in 
time complete recovery is obtained. 

In other cases the dislocation takes place in the course of some of 
the eruptive fevers or other febrile condition, sometimes without pre- 
vious notable pain in the joint and without the knowledge, at the time, 
of the patient. William W. Keen 2 collected eighty-four cases of 
arthritis occurring as a complication of typhoid and typhus fever, in 
forty-three of which dislocation took place, forty times at the hip, twice 
at the shoulder, and once at the knee. It is noteworthy that thirty- 
two out of thirty-five patients were under twenty years of age. 

It thus appears that these dislocations resemble those that are trau- 
matic in their sudden occurrence, the absence of any lesion of the 
bones, and the possibility of immediate and permanent reduction with 
complete restoration of function. 

The presence of a large effusion in the joint and the elongation of 
the ligaments have been assumed by all observers, and the actual pres- 
ence of an effusion of some amount has been demonstrated in some of 
the exceptional cases, knee and shoulder, where such demonstration 
was possible. On the supposition of this effusion and of the relaxa- 
tion of the ligaments produced by it, the production of the dislocation 
has been explained. Yerneuil has further called attention especially 
to the unopposed contraction of certain muscles as the immediate 
cause. 

If it is remembered that at the hip these dislocations are always 
backward upon the dorsum of the ilium, and are preceded by the long 
maintenance of the limb in the position of flexion, adduction, and 
inward rotation which so greatly favor the occurrence of this disloca- 
tion, and that the muscles are stimulated to contraction by the pain of 
the arthritis, it does not appear improbable that this contraction is not 
only the immediate but also the preponderant cause of the accident, 
and that the arthritis favors it not by overstretching the ligaments but 
only by supplying an amount of liquid that removes the obstacle created 
by atmospheric pressure. These two conditions, pain and effusion, 

1 Verneuil : Bull, de la Soc. de Chirurgie, 1883, p. 781. 

2 Keeu : Surgical Com plications and Sequelae of Typhoid, 1898. 



SPONTANEOUS DISLOCATIONS. 499 

would explain why the dislocation does not also occur in the course 
of adynamic diseases in which the limb often remains for a long time 
in the flexed position. 

Certainly the theory of the production of the dislocation by simple 
overdistention is incompatible with the easy reduction and mainte- 
nance of the reduction noted in several cases. It was unfortunate for 
some of the patients that their surgeons held to this theory, and were 
logical enough to refrain from attempting reduction and to leave the 
patients permanently crippled. y 

A few cases have been observed in which an acute purulent arthritis 
has been followed by dislocation; but in such cases it is always pos- 
sible that the capsule has been in part destroyed by the suppuration. 

Paralytic or "myopathic" dislocations are observed especially 
at the shoulder. The humerus is held up and kept in contact with 
the glenoid cavity by the tonicity of the attached muscles, and when 
this tonicity fails the weight of the limb causes separation of the bones 
and subluxation or complete dislocation. The cavity of the joint, 
thus enlarged, is filled by an effusion, but this effusion is the conse- 
quence of the separation rather than a favoring, precedent, and causa- 
tive condition, for it is presumably drawn from the surrounding tissues 
by suction, just as oedema appears under a dry cup. 

At the hip they are produced by the unopposed contraction of those 
muscles which have not been paralyzed. In Roser's three cases of 
spinal caries, mentioned above, the dislocation was dorsal, and the 
immediate cause was the contraction of the adductors no longer 
opposed by the pelvic-trochanteric muscles. The opposite form, dis- 
location upon the pubis, due to paralysis of the adductors and the 
consequently unopposed contraction of the muscles on the outer side 
and back of the hip, has been reported by Bradford l and Reclus. 2 

Another variety may be mentioned, in which by the unequal growth 
of parallel bones, the tibia and fibula or the radius and ulna, one of 
them is slowly dislocated. 

Voluntary dislocations is the name given to those which the indi- 
vidual can produce and reduce at will. Those in which the pecu- 
liarity has originated in a previous traumatic dislocation are due to 
rupture of some of the ligaments or attached muscles and have been 
described among the consequences of traumatic dislocations ; but a 
number of cases have been recorded in which this cause could not hv 
invoked in explanation. I have seen two such, both of the hip. 

Dislocations by destruction and dislocations by deformity are 
of less practical interest to the surgeon because less amenable to treat- 
ment, and are to be regarded rather as incidents in, or symptoms of, 
other diseases than as morbid entities. 

In the former, dislocations by destruction, Volkmann included those 
dislocations which occur in the course of chronic tubercular disease 
of joints or as a consequence of acute traumatic suppurative arthritis. 
Frequent examples are seen at the hip and knee. 

In consequence of the destruction of the articular ligaments or of 

1 Bradford : Boston Medical and Surgical Journal, 1883, vol. eviii. p. 73, 

2 Eeclus : Bevue de Med. et de Chir., 1878, p. 176. 



500 DISLOCA TIONS. 

the bones themselves an abnormal mobility is created which allows 
the bones readily to be displaced by the action of gravity or by mus- 
cular contraction. At the hip this displacement is usually upward 
and backward; at the knee the well-known subluxation of the tibia 
backward or upward is produced by the contraction of the hamstring 
muscles, or, if the patient lies long upon one side and the destruction 
is well advanced, the displacement may be lateral to the distance of an 
inch or even more. 

In the latter, dislocations by deformity, Volkmann included the dis- 
locations which occur in the course of such affections as the morbus 
coxo3 senilis and in the arthropathies of nervous origin, "Charcot's dis- 
ease," in which the articular ends of the bones disappear by absorption 
without suppuration. 

The remaining form has been specially studied, so far as I know, 
only by Madelung, 1 and only at the wrist ; the dislocation was always 
of the carpus forward, and was accompanied by marked changes in 
the shape of the radius and of the bones of the first row of the carpus. 
The cause appeared to be overexertion, or, rather, prolonged and fre- 
quently repeated exertion in patients who, presumably, were predis- 
posed to the change by defective vitality of the bones. Volkmann 
includes such cases under the general head of disturbances of growth 
of joints. 2 

1 Madelung : Deutsche Gessellschaft fur Chirurgie, 1878, p. 259, and Arch. f. klin. 
Chir., vol. xxiii. 

2 Volkmann : Loc. cit., p. 692. 



CHAPTER XXXVII. 

DISLOCATIONS OF THE LOWER JAW. 

Dislocations of the lower jaw constitute from 3 to 6 per cent, of 
all dislocations according to the tables in Chapter XXVII. They 
may be bilateral or unilateral, the former being the more common, in 
the proportion of about 5 to 2 according to Malgaigne, who found 54 
bilateral in a total of 76 cases which he collected. Of these 54, 31 
were in women, and this greater frequency in the female sex is univer- 
sally recognized. The injury is rare in infancy and old age ; it has 
been observed in patients eighteen and seventy-two years old, and has 
been caused in the new-born child by obstetric manipulations. 

In the great majority of cases the dislocation is forward, the condyle 
of the jaw passing in front of the articular eminence at the root of the 
zygoma. A few instances have been reported of double or single dis- 
location backward with fracture of the wall separating the articular 
cavity from the external auditory canal, of dislocation upward into 
the cavity of the cranium, and of unilateral dislocation outward with 
or perhaps without, fracture of the body of the jaw. These are, how- 
ever, entirely exceptional and may be briefly described before proceed- 
ing to the consideration of the common form. 

Dislocation Backward. 1 

This rare injury has been reported in thirteen cases, most of them 
women. It may be unilateral but is usually double. The pathology 
is not known and it is not clear where the condyle lodges or how it 
becomes fixed in its new position, possibly by interposition of the 
meniscus. It has occurred during yawning and during sleep, once by 
a blow upon the chin, three times by an inflammatory or rheumatic con- 
traction of the temporal muscle, and three times by forcible pressure of 
the jaws together and the act of swallowing. In Hacker's case it oc- 
curred repeatedly in a woman who had long suffered from frequently 
recurring forward dislocation. 

A marked symptom is inability to open the mouth, the lower jaw 
being held firmly against the upper and a little behind its proper 
position. Reduction has been easy. 

Dislocation Backward with Fracture. 

Dislocation backward with fracture of the posterior wall of the 
articular cavity is caused by great violence received upon the chin and 

1 Steiner : Arch. fur. klin. Chir., 1893, vol. 45, p. 622. Hacker: Beitrage zur. klin. 
Chir., 1906-7, vol. 52, p. 748. 

501 



502 DISLOCATIONS. 

acting from before backward. One or both condyles may be driven 
through the wall into the external auditory canal, breaking the bone 
and lacerating or pushing backward the outer cartilaginous portion. 
The production of the lesion is probably easier when the molar teeth 
are lacking from the upper or lower jaw, or if the mouth is partly open 
when the blow is received. The symptoms are pain in, and bleeding 
from, the ear, immobility of the jaw, the mouth being held partly open, 
and displacement backward, as shown by the relations of the front 
teeth to each other. The absence of the condyle from* its normal posi- 
tion can be recognized by the touch, and the auditory canal is seen or 
felt to be obstructed by the displacement of its anterior wall. 

Dislocation Upward. 

Le Fevre 1 reported an interesting and very exceptional case in 
which the injury was caused by a fall from a height, the blow being 
received upon the chin. The jaw was displaced slightly backward and 
to the left, the teeth were close together, and the mouth could not be 
opened. Slight bleeding from the left ear. The diagnosis of fracture 
of the condyle was made. The patient was dismissed in the fourth 
week, still experiencing difficulty in mastication and deglutition. 
Subsequently he suffered from violent headache, had several attacks 
of convulsions, and died about six months after the receipt of the 
injury. The autopsy showed that the roof of the glenoid cavity had 
been fractured, the condyle had passed into the cranium between the 
fragments, the neck of the condyle was in part destroyed, the dura 
mater was extensively inflamed and thickened, and there was a large 
abscess in the middle lobe of the brain. 

Dislocation Outward. 

Robert 2 received at the Hopital Beaujon a patient who had been in- 
jured by the passage of the wheel of a cart across the right side of his 
face. The chin was deviated to the right, and the mouth was held open. 
The left condyle of the lower jaw could be distinctly felt under the skin 
above the root of the zygoma. Greatly surprised at this displacement 
Robert sought for and found a vertical fracture of the body of the bone 
on the right side just in front of the ramus. The left coronoid process 
remained under the temporal fossa, the sigmoid notch crossing and em- 
bracing the zygoma. Reduction was made by pressing the left ramus out- 
ward until the condyle was freed from its contact with the upper surface 
of the zygoma, and then drawing it downward and inward to its place. 

Xeis 3 reported a similar case and collected others. 

Dislocation of the Jaw Forward. 

This, the common form, is usually caused by muscular action, as in 
laughing, scolding, yawning, or vomiting, or exceptionally by violence 

1 Le Fevre : Journal Hebdomad aire, 1834, vol. iii. p. 333. 

2 Robert : Archives generates de Med., 1845, vol. vii. p. 44. 

8 Neis : Luxation du Maxillaire inf. en haut ou dans la fosse temporarle. Th&se de 
Paris, 1879, No. 252. 



DISLOCATIONS OF THE LOWER JAW. 503 

in widely opening the month to introduce some large object, such as an 
apple or the fist, or in drawing a tooth, or by a blow upon the jaw. 

In order to understand this mechanism it is necessary to recall the 
construction and normal action of the joint. The lower jaw is attached 
to the skull by a synovial capsule which is strong on its outer side (the 
external lateral ligament), by an internal lateral ligament not in imme- 
diate relations with the joint but extending from the spinous process of 
the sphenoid bone to the margin of the inferior dental foramen, and by 
the stylo-maxillary ligament, a strong band extending from the styloid 
process of the temporal bone to the posterior border of the ramus of 
the jaw. The joint is occupied by an intra-articular cartilage or menis- 
cus which overlies the upper surface of the condyle and accompanies 
it in its normal movement forward from the glenoid cavity to the emi- 
nentia articularis when the mouth is opened. In front of the point to 
which the condyle thus moves forward the surface of the eminentia 
articularis is inclined slightly upward to become continuous with the 
much narrower lower surface of the zygoma. The fibres of the mus- 
cles attached to the ramus which close the mouth run upward and for- 
ward, and only those belonging to the deep posterior portion of the 
masseter are vertical or inclined backward. 

Since the condyle moves forward when the chin descends, the centre 
of motion of the jaw is not in the condyle, but at a point below it at 
or near the dental foramen, and as the angle of the jaw is at the same 
time moved backward the axis of the ramus notably changes its 
relations to the direction of the fibres of the masseter, bringing the line 
of the posterior ones behind the centre of motion where their contrac- 
tion tends still further to open the mouth or to keep it open. Still, 
the cause, when muscular, is rather to be found in the excessive action 
of the external pterygoid, aided by relaxation of the external lateral 
ligament, which latter condition is produced by the wide opening of 
the mouth, as will be explained more fully in the following section. 

Pathology. The opportunities directly to examine cases of disloca- 
tion of the jaw have been very few, and experiments upon the cadaver 
cannot entirely take their place, but it appears to be established that 
Malgaigne's opinion that the condyle did not advance more than one 
or two millimetres beyond the point on the articular eminence which 
it normally reaches is not correct, but that the advance is considerably 
greater. In an autopsy made by Demarquay in a case of recurrent dis- 
location the condyle was in front of the transverse part of the zygoma ; 
the interarticular disk was behind it. It also appears that the rupture 
of the capsule, when it occurs, takes place in front between the menis- 
cus and the condyle, but sometimes the meniscus accompanies the con- 
dyle without rupture of the capsule. This makes the persistence of 
the dislocation, and especially the fixation of the jaw, difficult to 
explain. The earliest theory, that of Petit, the contraction of the 
posterior fibres of the masseter, is generally rejected as inadequate. 
Another, also advanced by the earlier writers and recently brought 
forward again by Nelaton and accepted by Malgaigne, and supported 
by at least one specimen which is figured in Malgaigne's At/as, Plate 
XVII., iig. 1, is that the coronoid process becomes engaged under 



504 DISLOCATIONS. 

the malar bone. That this may be an occasional adjuvant cause must 
be admitted on the facts presented, but that it is not the sole cause, 
and probably not even a frequent one, is proved by experiments upon 
the cadaver which have shown the fixation to persist after removal of 
the coronoid process, and by the fact that in Xelaton's specimen the 
process is unusually long. 

The slightly upward inclination of the anterior surface of the emi- 
nentia articularis against which the displaced condyle rests is not of 
itself sufficient, and the most recent theory, suggested by Demarquay * 
and thoroughly studied by Mathieu, 2 that the return of the condyle is 
opposed by the meniscus beyond which it has passed, seems to be open 
to the objections that the meniscus is so freely movable backward that 
it would be readily pushed back into the glenoid cavity by the return- 
ing condyle, and that in some cases it accompanies the condyle in its 
excursion. In a case in which I was unable to reduce I 3 found on 
exposing the joint that the meniscus had been torn from the condyle 
and was so lodged in the glenoid cavity that the condyle could not 

Fig. 270. 





Diagrammatic of the external lateral ligament of the lower jaw. A, when the mouth is open ; 
B, when the^condyle is dislocated forward. 

enter it. After removal of the meniscus the dislocation was easily 
reduced. An autopsy reported by Perier 4 of a case of recurrent dislo- 
cation showed absence of the anterior portion of the meniscus and 
lodgement of the remainder behind the condyle after reduction. These 
prove not that the meniscus is the cause of the fixation, but that it may 
prevent complete reduction. 

The cause must be found, I think, in the ligaments, the external 
lateral and perhaps the posterior portion of the capsule, and this opin- 
ion is supported by the tenseness of the lateral ligament observed by 
Weber 5 and Maisonneuve 6 upon the cadaver, by the anatomical 
relations of the parts, and also by the experience of Kramer, 7 who 
operated upon a case five weeks old and found reduction easy after he 
had detached a portion of the masseter and divided the tense external 
lateral ligament. The mechanism of its action I conceive to be as 
follows : The external lateral ligament, forming the anterior part of 

i Demarquay : Bull, de la Soc. de Chirurgie, 1863, vol. iv. p. 119. 

2 Mathieu: Arch. gen. de Med., 1868, vol. ii. p. 129. 

3 Stimson: Trans. N. Y. Surg. Soc., Annals of Surgery, March, 1898. 

4 Perier : Bull, de la Soc. de Chirurgie, 1878, p. 222. 

s Weber: Handbuch de allg. und spec. Chir., vol. iii. Abt. 1, p. 288. 

fi Maisonneuve : Comptes-rendus, Acad, des Sciences, 1862, p. 654. 

* Kramer : Centralblatt fur Chirurgie, 1901, p. 369. 






DISLOCATIONS OF THE LOWER JAW. 505 

the outer portion of the capsule, extends from the articular eminence 
downward and backward to the neck of the condyle, its attachment to 
the eminence being posterior to the point at which the lower surface of 
the latter begins to incline upward. This ligament (Fig. 270) is too 
short to allow the jaw to take such a position when the condyle is 
dislocated forward that the long axis of the neck shall coincide with 
that of the ligament. When the mouth is widely opened the liga- 
ment is relaxed by the approximation of its points of attachment, and 
the condyle passes forward ; then, as the mouth is partly closed, the 
ligament becomes tense before the condyle has moved back past it, and 
thus its further movement backward is prevented, and while it remains 
thus displaced any force that tends to close the mouth increases the 
obstacle to replacement by making the ligament more tense and press- 
ing the bones more firmly together. Such a force is naturally and con- 
stantly exerted by the powerful muscles of mastication, stimulated to 
contraction as they are by their forcible elongation and the pain and 
anxiety of the patient. The practical inference to be drawn from this 
explanation, if it is correct, is that reduction should be sought, not by 
crowding the body of the jaw downward and backward by pressure 
upon the molar teeth, but by first depressing the chin if possible, 
opening the mouth wider, so as to relax the ligament, and then press- 
ing the condyle backward and closing the mouth as it passes the artic- 
ular eminence on its way back. 

Symptoms. The symptoms of bilateral dislocation forward are that 
the mouth is held open, the lower jaw immovable and projected some- 
what forward ; exceptionally, only the projection is present, and the 
mouth can be closed. Speech is indistinct, swallowing difficult, and 
chewing impossible. The condyle can be felt in advance of its usual 
position, and a depression marking the empty glenoid cavity can be 
felt in front of the ear. The checks are flattened, and the saliva 
escapes from the mouth. The masseter and temporal muscles are 
usually tense, and the upper anterior portion of the former is raised 
by the coronoid process. 

If the dislocation is unilateral the physical signs are found upon 
only one side, the chin is turned to the opposite side, and the func- 
tional disability is less. 

Prognosis. The prognosis is favorable both as regards the reduction 
of the dislocation and the degree of disability if it remains unreduced, 
but somewhat unfavorable in that recurrence is quite probable. If it 
remains unreduced the parts appear slowly to adjust themselves to their 
new relations and finally to permit more or less satisfactory approxi- 
mation of the jaws and restoration of the functions. 

Treatment. The dislocation is one which, as a rule, can be easily 
reduced, one indeed in which, as has been already said, reduction has 
often occurred spontaneously. The methods employed have, perhaps 
in consequence of this fact, been numerous, and have varied greatly in 
the objects aimed at, if not in the actual mechanism by which they 
have accomplished the reduction. It can be shown, 1 think, that many 
of the methods and procedures have been successful not because they 
met the ideas of their originators concerning the obstacle to be over- 



506 DISLOCATIONS. 

come, but because they overcame or avoided another obstacle which 
had not been recognized. With few exceptions the aim of the different 
methods has been directly to depress the condyle and then to press it 
backward, and this aim has been accomplished by direct pressure down- 
ward upon the molars, or indirectly by raising the chin after having 
placed a wedge between the back teeth. Those who found the obstacle 
in the hooking of the coronoid process under the malar bone sought to 
disengage the process by opening the mouth more widely, and then 
pressed the jaw backward ; while others, again, pressed the bone directly 
backward by placing the thumb and forefinger of one hand against the 
coronoid processes and then elevated the chin by a slight blow upon it 
from beneath. It is noteworthy that some of the gentlest methods, 
some which approach most closely to that which I conceive to be the 
rational method, were employed by the earliest surgeons, even by Hip- 
pocrates, and were again and again resumed only to be as often neglected 
and forgotten. Hippocrates's method, as quoted by Malgaigne, was to 
lower the chin a little in order, according to Galen, to free the coronoid 
process from the malar bone, and then to press the jaw backward, the 
patient being meanwhile encouraged to relax his muscles and yield 
himself as completely as possible to the effort made in his behalf. 
Although the intention and the supposed effect was to free the coro- 
noid process, yet the wider opening of the mouth relaxed the lateral 
ligaments and facilitated the backward propulsion. 

In 1862 Maisonneuve again revived the plan, after having observed 
in many experiments upon the cadaver that the external lateral, spheno- 
maxillary, and stylo-maxillary ligaments were tense and that after their 
division the dislocation could be reduced with great ease. He ascribed 
the fixation to the pressure of the condyle against the zygoma, a press- 
ure " maintained by the combination of the passive resistance of the 
ligaments and the energetic contraction of the elevator muscles," and 
proposed to reduce by direct backward propulsion after diminishing 
the pressure by opening the mouth more widely. 

It is unquestionable that in this, as in most other dislocations, the 
obstacles to reduction are multiple, and that contraction of the muscles 
is one of them, and that it especially opposes reduction because it 
directly resists the attempt to place the bones in the most favorable 
position. It is also true that methods of reduction are habitually 
successful which are not based upon correct anatomical principles, but 
nevertheless those principles exist and are the same as in other dislo- 
cations ; the opposing ligaments must be relaxed, and the bone should 
follow in returning to its socket the route by which it escaped from it. 
In the great majority of cases, as has been said, dislocation takes place 
while the mouth is widely open and the ramus is inclined upward and 
forward. Theoretically, then, the same position should be given to it 
as a preliminary to reduction, and although the opposition of the mus- 
cles may create practical difficulties in the way of accomplishing this 
which will prevent its universal use and cause other methods to be 
preferred in the simple cases, yet in all difficult cases and whenever 
this opposition has been annulled by ansestheisa this method should be 
employed : the mouth should be widely opened and the jaw should be 



DISLOCATIONS OF THE LOWER JAW. 507 

pressed backward, or backward and slightly downward. The press- 
ure may be conveniently made by the thumbs placed inside or outside 
the mouth against the anterior edges of the ascending rami, the head 
of the patient being solidly supported behind, or by pressing with the 
forefingers against the front of the ramus, outside the mouth, and the 
middle fingers against the side near the angle, while the thumbs and 
other fingers grasp the body near the symphysis. 

In the method by forcible depression of the posterior portion of the 
jaw the thumbs may be used alone by placing them upon the lower 
molar teeth and pressing downward and backward. It is well to 
guard them against bruising by covering them with cloths or leather, 
and when the reduction is accomplished they should be rapidly with- 
drawn or slipped to the outer side of the teeth to escape being bitten, 
an accident that has happened to several surgeons and has indeed been 
the cause which led to the invention of other procedures. 

Instead of direct pressure with the thumbs, hinged instruments 
have been used, taking their bearings upon both sets of molars. 

In a bilateral case five months old in which other measures had failed 
McGraw 1 reduced by passing through an incision a sharply curved strong 
steel hook into the sigmoid notch, and with it drawing the mandible forci- 
bly downward and backward while pressure was made upon the chin. In 
a bilateral case thirteen months old Brockway 2 succeeded by exposing 
the condyles and forcing them back by direct pressure on them. 

Mazzoni treated an irreducible bilateral dislocation of eight months' 
standing in a woman twenty-seven years old by excision of both con-' 
dyles, with an excellent functional result. 

After reduction the mouth should be kept closed by a bandage and the 
patient fed on soft food for two or three weeks. It is not unlikely that the 
marked tendency to recurrence so commonly observed is the result of in- 
opportune use of the jaw, perhaps also, in part, of the favorite method of 
reduction which tends to elongate or rupture the lateral ligaments. 

Annandale 3 successfully treated two cases of recurrent dislocation by 
opening the joint and suturing the meniscus to the periosteum. Irritating 
injections into the peri-articular tissues have also been employed. 

Pathological or Consecutive Dislocations. 

Pathological or consecutive dislocations are uncommon, and only in a 
few cases 4 has the condyle, eroded and deformed by antecedent inflam- 
mation, been found outside its cavity and sometimes united by bony union 
to the skull. 

Congenital Dislocations. 

The only example of this condition of which I have found mention, if 
a foetal monster reported by Guerin be excepted, is one described by R. 
W. Smith. 5 The patient was a congenital idiot who died at the age of 
thirty-eight years. The dislocation existed upon the right side and was 
the result of defective development of the constituent parts of the joint. 

1 McGraw : Med. Record, 1899, vol. lvi, p. 511. 

2 Brockway : Johns Hopkins Hosp. Bull., May, 1890. 

3 Annandale Lancet, 1887, i. p.(>411. 

i OurltPath. Anat. der Gelonkrankheiten, p. 109, Cases 5, 11, 15. 
5 R. W. Smith : Fractures and dislocations, p. '273. 



CHAPTEE XXXVIII. 

DISLOCATIONS OF THE VERTEBRA AND OF THE OCCIPUT 
FROM THE ATLAS. 

Classification and pathology, secondary changes, etiology, symptoms and diag- 
nosis, prognosis, treatment — Dislocations of the occiput, atlas, lower six 
cervical vertebrae, dorsal vertebra?, lumbar vertebrae. 

The study of dislocations of the vertebras is closely associated with 
that of fractures of the same bones, because in many cases the differ- 
ential diagnosis between a fracture and a dislocation cannot be made 
with certainty, and because the associated lesions and consequences are 
the same. For some of the latter, therefore, the reader is referred to 
the chapter on Fractures of the Vertebras. 

Concerning the frequency of dislocations of the vertebras widely 
different opinions have been held ; some (Delpech) denying even the 
possibility of dislocation without fracture, others thinking them ex- 
tremely rare, and others, again, claiming that they are quite common. 
The most notable member of the last group is Porta, who, according 
to Blasius, observed no less than twenty-seven cases in thirty years. 
By far the most valuable contribution to the settlement of this question, 
and indeed to the whole subject, is the monograph of Blasius, 1 who 
collected 294 reported cases, of which 185 were dislocations, 37 dias- 
tases, and in 72 it remained undetermined to which of these two classes 
the lesion belonged. Although an autopsical examination was made 
in 1 74, yet in 38 of these the account is so defective that the variety 
and seat of the injury cannot be determined ; and in only 172 of the 
294 cases can these details be said to have been established. By far 
the most common seat is the cervical region, then the dorsal, and last 
the lumbar region, in which only a very few cases have been observed. 
The certain cases were divided among the decades of life as follows : 
first, 7 ; second, 17 ; third, 25 ; fourth, 15 ; fifth, 14 ; sixth, 6. 

The difference of opinion above mentioned regarding the frequency 
of the occurrence of the injury in general, doubtless depends in part 
upon the definitions which the different authors have adopted, since 
some accept as dislocations only those cases which are not complicated 
by fracture, while others accept also those in which an associated frac- 
ture can be rightly deemed unessential to the production of the dislo- 
cation. The latter view is in harmony with the classification of other 
dislocations, and will be adopted here ; a dislocation of a vertebra being 

1 Blasius: Die traumatische Wirbelverrenkungen, in Vierteljahrsclnift fur prakt. Heil- 
kunde, 1869, vol. cii. ciii. 
508 



DISLOCATIONS OF THE VERTEBRJE. 509 

defined as an injury in which the adjoining articular processes on one 
or both sides have been partly or completely separated from each other, 
with or without avulsion of portions of the body of either vertebra or 
fracture of one or more processes. The term dimtasis is applied to 
those dislocations in which, the intervertebral disks and other ligaments 
having been torn, the vertebrae are longitudinally separated from each 
other in front or behind, but have not also been so horizontally dis- 
placed that the articular surfaces on either side have been put out of 
line with each other. 

The terminology employed to indicate the seat and variety of the 
displacement has also varied with the different writers, some speaking 
of the upper, others of the lower, vertebra as the one that is dislocated, 
while others have sought to avoid misunderstanding by using such a 
phrase as " dislocation of the fifth upon the sixth." The latter form 
can be advantageously employed in the report of cases, or whenever 
any doubt might arise as to the meaning, but it will be convenient 
here to follow the more general practice, and speak of the upper ver- 
tebra as the one that is dislocated, and of the direction and character 
of its displacement as those of the dislocation. 

Classification and Pathology. The relations of the vertebras to each 
other are so complex, and the combinations of different directions 
which the displacements may present are so variable and numerous, 
that a classification of the varieties based upon these directions is not 
only very complicated, but it also fails to offer comparative advantages 
sufficient to compensate for its complexity. The classification made 
by Hueter, according to the character of the movement or the direction 
of the force which produces the dislocation, is simple, and at the same 
time indicates the main features of the displacement and suggests the 
proper method of reduction. It fails, however, to distinguish between 
the varieties ; and, therefore, while adopting it, it has appeared desir- 
able also to use in connection with it other terms indicative of special 
features. 

The provisions for normal motion between adjoining vertebrae consist 
in the elasticity and compressibility of the intervertebral disks between 
the bodies and in the articulations placed just behind them upon the 
arches. The normal range of motion, though varying in the different 
portions of the column, is at best slight, and can be referred in the 
main to two axes for each pair, one of which lies in the median plane 
and passes through the centre of the disk from behind forward, with 
an inclination downward of its anterior end which is slight in the 
lumbar and lower dorsal regions, more marked in the upper dorsal, 
and greatest in the cervical regions. The other axis is a horizontal 
transverse one, passing through the posterior part of the disk. 
Motion about the first axis produces a lateral bending of the col- 
umn, and, in the cases in which the axis is inclined downward and 
forward, with this motion must be associated a rotation of the upper 
vertebra by which the anterior surface of its body is turned to the side 
toward which the column is inclined ; and the greater the inclination 
of the axis, f.be more narked is this associated rotation. The move- 



510 



DISLOCATIONS. 



Fig. 271. 



ment is arrested by the contact of the margins of the adjoining articular 
surfaces with their bases on the concave side, and if it persists beyond 
this point dislocation is produced, the opposite inferior articular surface 
of the upper vertebra being raised above the one 
with which it articulates by the lateral bending, 
and being carried forward by the rotation. To 
these dislocations Hueter gives the name disloca- 
tions by abduction or rotation. 

Motion about the other, transverse, axis pro- 
duces a bending forward (or, to a less degree, 
backward) of the column, during which the ante- 
rior portion of the disk is compressed, the pos- 
terior portion stretched, and both inferior articular 
surfaces of the upper vertebra are moved upward 
and forward along the superior articular surfaces 
of the underlying vertebra. The movement is 
checked, when its normal limit is reached, by the 
ligaments of the joints and arches, and, if these 
yield, a dislocation is produced, in which the 
inferior articular processes of the upper vertebra 
pass forward and in front of those with which they 
articulate — dislocation by flexion. 

Under the first head, dislocations by abduction, 
are to be included the complete or incomplete uni- 
lateral dislocations forward or backward, and the 
bilateral dislocations in opposite directions, de- 
scribed as distinct forms under these names by 
Blasius, all of which, with one exception (the 
unilateral dislocation backward) represent only 
different degrees of the same displacement. In- 
stead of being entirely separated from each other, 
the articular surfaces may remain in contact at 
their edges. If the displacement is somewhat 
greater, the inferior process of the upper vertebra 
passes further forward, and sinks into the notch between the body and 
the superior articular process of the lower vertebra (complete unilat- 
eral dislocation, Fig. 272), and at the same time the inferior process on 
the opposite side may be carried backward by the movement of rotation 
(bilateral dislocation in opposite directions). The unilateral dislocation 
backward, of which Blasius refers to a few examples exclusive of those 
of the occiput upon the atlas, may, I think, be attributed to the same 
mechanism, the displacement being effected in consequence of the 
yielding of the ligaments of the joint on the side toward which the 
body is bent, instead of on the opposite side as in the other cases. 
In a case observed by Cloquet, and briefly mentioned by Blasius, 
the second lumbar vertebra was dislocated in this manner, the dis- 
location being complicated, but unessentially, by fracture of the 
body and arch of the vertebra; all the processes w T ere uninjured. 
The patient survived several years, and the condition of the parts was 




Direction of the median 
axis in the different sec- 
tions of the spinal col- 
umn. (Henke.) 



DISLOCATIONS OF THE VERTEBRA?. 511 

determined by autopsical examination. Under the second head, disloca- 
tions by flexion, are included bilateral dislocations forward or backward. 
The force continuing to act after the normal limit of forward flexion of 
the column has been reached, the ligamenta subflava are ruptured, and 
the posterior portion of the intervertebral disk is torn or separated from 

Fig. 272. 




Complete unilateral dislocation by rotation or abduction ; cervical vertebra. (Konig.) 

the vertebra with or without avulsion of a portion of the bone ) the 
articular processes of the upper vertebra lodge in front of those of the 
lower in the notches. Sometimes the processes do not pass entirely 
beyond each other, but remain in contact at their extremities ; and 
sometimes, the movement being accompanied by slight rotation of the 
vertebrae upon each other, one articular process is displaced further 
forward than the other. The lumen of the vertebral canal may be 
seriously encroached upon in this dislocation, and its contents injured 
by compression against the upper edge of the body of the lower ver- 
tebra. 

The mechanism of the double dislocation backward, of which a few 
cases have been accurately observed, has not been demonstrated, but 
the possibility of its production by extreme dorsal flexion of the column 
is such that it may, provisionally at least, be placed in this class. The 
motion is arrested by bony contact at the arches, and by the interver- 
tebral disks, the efficiency of whose resistance is increased by their 
greater distance from the fulcrum about which the rupturing move- 
ment must turn. It is interesting to note that in a case reported by 
Stanley, 1 dislocation backward of the fifth cervical vertebra, the upper 
five vertebrae were firmly united together by bony fusion. The dis- 
placement was so great that the body of the fifth rested upon the 
laminae and spinous process of the sixth. The additional leverage 
created by this anchylosis may be invoked as an argument in favor of 
the theory of production by dorsal flexion. 

Transverse dislocation has been diagnosticated in several cases, but 
the only one in which sufficient anatomical proof has been obtained is the 
following mentioned by Charles Bell. 2 A child was run over by a stage- 
coach and died of croup thirteen months later. The last dorsal ver- 

1 Stanley: Edinburgh Medical and Surgical Journal. October, 1841, p. 404. 

2 Bell: Injuries to the Spine and Thigh-bone, 1S24. p, 25, 



512 D1SL CA TIONS. 

tebra was found completely displaced to the left side of the first lum- 
bar with slight chipping of the bone. The articulation between these 
vertebra is of such a character that this form of dislocation would 
seem impossible without a fracture of the articular processes, and prob- 
ably it may still probably be deemed so except in a child. The same 
anatomical conditions exist in the lumbar vetebrae, but in the dorsal 
and cervical regions the articular surfaces look backward and forward 
or are only slightly inclined to one side, consequently this form- of dis- 
location must there be regarded as possible. 

In the greater part of the dorsal region it would necessarily be asso- 
ciated with dislocation of the vertebral end of the corresponding rib. 

In all the clinical cases quoted by Blasius, with one exception, the 
cervical vertebrae were concerned, and he says that the correctness of 
the diagnosis is very doubtful in all. 

The main groups and varieties, then, are as follows : 
Dislocations by flexion, ventral or dorsal. 
Bilateral forward. 
Bilateral backward. 
Dislocations by abduction or rotation. 

Unilateral forward ) , , . -. , 

TT .1 , i , i -. > complete or incomplete. 
Unilateral backward J r r 

Bilateral in opposite directions. 

Transverse.(?) 

The associated lesions comprise rupture of the various ligaments, 
muscles, bloodvessels, and nerves, fracture of the bones, and injuries 
of the spinal cord and its membranes, and those later changes which 
may be induced by the primary ones. 

The intervertebral disk is always ruptured or torn away from one or 
the other vertebra, and this rupture or separation is almost invariably 
complete, and is accompanied by the avulsion of larger or smaller 
fragments of the bone. In one or two cases the disk appears to have 
been crushed. 

The capsular ligament, on one or both sides according to the char- 
acter of the displacement, is always torn. The anterior and jyosterior 
ligaments are either torn, wholly or in part, or stripped from their 
attachments to the bodies of the vertebrae, sometimes bringing with 
them in the latter case portions of the bone. The ligaments between 
the lamince and the spinous processes are either torn or put upon the 
stretch, and those between the transverse processes were torn in the 
only reported case found by Blasius in which their condition was men- 
tioned. Instead of rupture of the ligaments fracture of the processes 
to which they are attached may occur, and various other fractures of 
the adjoining processes or of more distant parts are frequently 
observed. 

The surrounding and the attached muscles may be torn by the dis- 
placement or by the direct action upon them of the dislocating vio- 
lence. 

The veins coming from the bodies of the vertebrae and those of the 
meninges of the cord are so large and their relations with the bones 






DISLOCATIONS OF THE VERTEBRAE. 513 

and ligaments are so close that hemorrhage is always free and some- 
times very profuse. 

In dislocations of the cervical vertebrae the vertebral arteries so 
commonly escape injury that the possibility of their rupture has been 
denied, but in a case received into St. Thomas's Hospital l the verte- 
bral artery was found to have been torn and a large amount of blood 
to have escaped into the vertebral canal and among the muscles. 
Blasius admits this case into his list, although all the processes of the 
fourth vertebra were broken. 

The nerve trunks at their point of emergence through the interver- 
tebral foramina may be compressed or torn on one or both sides 
between the articular process of one vertebra and the body or pedicle 
of the other ; and in the lumbar or lower dorsal regions the nerves 
constituting the cauda equina have repeatedly been found torn across 
or compressed between the body and laminae of the adjoining vertebrae. 

The spinal cord and its membranes may entirely escape injury, and 
if injured, the lesion may present any grade between simple compres- 
sion and complete rupture. The injury may be caused by pressure of 
the bone against the cord or by the direct elongation of the latter. 
All the lining membranes may be torn, entirely across or only in part, 
or one of them alone may be ruptured. Their rupture is necessarily 
accompanied by the extravasation of blood, usually profuse, between 
the dura and the bone and amid the meninges. Occasionally an extra- 
vasation of blood has been found within the cord itself; thus, in a 
case reported by Martini, 2 one of diastasis between the fourth and 
fifth cervical vertebras, in which there was complete rupture of all the 
ligaments and separation to such an extent that the finger could be 
passed between the bones, the meninges were not torn, and the only 
lesion found in the cord was a clot three centimetres long in its centre 
and involving also the cortical substance. A similar case has recently 
been reported by Qu6nu. 3 It is worthy of note that in three reported 
cases 4 in which extensive paralysis was present the autopsy failed to 
show any lesion of the cord, and that in others there has appeared to 
be no fixed relation between the extent of the paralysis and the ana- 
tomical lesions found in the cord. Probably these three, and the two 
preceding, were cases of hsematomyelia. In other cases the cord has 
been found torn while the ligaments have been only slightly injured. 

The analysis made by Blasius to determine the relative frequency 
and severity of injury to the cord in the different forms and at differ- 
ent seats of dislocation shows that the danger is greatest in disloca- 
tion of the lower cervical vertebrae, the fifth and especially the sixth, 
although even there the cord may entirely escape injury. In the 
variety which he terms "unilateral forward" (dislocation by abduction 
or rotation) the .danger is less than in the " bilateral forward " or 

1 Medico-Chirurgical Review, 1831, vol. xiv. (18 of analyt. series), p. :2 - 27. 

% Martini: Schmidt's Jahrbueher, 18(51, vol. ex. p. 195. 

3 Quenu : Le Progres Medical, February 27, 1887. 

4 Colborne: Provincial Medieal and Surgical Journal, vol. ii. p. 50; Hafner: Zeit- 
sohriftfur Wundarzte nnd Geburtshelfer, 1856, vol. ix. p. 241); and Porta: Delia lussa- 
zioni delle vertebre, 1864, quoted by Blasius. 
33 



514 DISLOCATIONS. 

" backward " (dislocation by flexion) ; in 7 autopsies the cord was 
found injured iu 6, and of 45 cases observed clinically, all of the neck, 
in 9 there was evidence of injury or compression of the cord, which 
disappeared in 5 and was followed in 4 by inflammatory and softening 
processes in the cord. The variety which he terms " bilateral in oppo- 
site directions " appears particularly free from this danger ; in the 
few cases he collected paralysis was exceptional and temporary. Of 8 
cases of bilateral dislocation backward examined post mortem, the 
cord was uninjured in 2, and more or less severely injured in 6 ; of 6 
clinical cases, in 3 there was no paralysis, and in 3 the paralysis was 
temporary. Of 52 cases of bilateral dislocation forward, the cord was 
uninjured in 17, and was injured seriously and irreparably in 11 ; in 
the remaining 24, either recovery followed or a distinction cannot be 
made between the effects of the mechanical violence inflicted upon the 
cord by the dislocation and those of the later inflammatory and nutri- 
tive changes. It must be remembered that in most of the clinical 
cases our knowledge of the exact character of the lesion of the skel- 
eton is defective. It has recently been shown that hemorrhage within 
the gray matter of the cord, hcematomyelia, may be produced by a 
temporary diastasis of the lower cervical and upper dorsal region, and 
even without recognizable injury of the column or its ligaments. And 
yet there is, at first, a motor paralysis which may be as complete as 
after transverse rupture or crush of the cord. (See Chapter XI., 
Fractures of the Vertebrae, pp. 151, 153.) 

Blasius l summarizes the analysis as follows : in no form of disloca- 
tion is injury of the spinal cord a necessary consequence ; such injury 
is less to be expected in unilateral dislocation, and in unilateral dislo- 
cation forward of the cervical vertebrae it is always, or almost always, 
only a simple compression without crushing ; in bilateral dislocation 
backward or forward, either of the dorsal or cervical vertebrae, the 
cord is exposed to more serious lesions and seldom escapes entirely 
uninjured, and when the displacement is forward the cord is mechan- 
ically affected in most cases, but the cases of severe injury are fewer 
than those in which all injury is escaped ; finally, the danger is least 
in bilateral dislocation in opposite directions. 

Secondary Changes. When the patients survive for a sufficient 
length of time the signs of a more or less acute inflammatory reaction 
appear. AVhile this reaction is not frequent or usually severe, yet 
in a number of cases pus has been found in the meninges and even 
in the centre of the cord itself. The cord may be slightly soft- 
ened and changed in color, or it may be reduced to pulp, and this 
change may involve only the portion corresponding to the dislocated 
vertebra or it may extend to a greater or less distance above and below. 
It is probable also that other changes observed after fracture of the 
vertebrae, such as extensive suppuration within the pia and the substi- 
tution of fibrous tissue for the nervous elements of the cord, may take 
place, for the conditions are practically the same. 

1 Blasius : Loc. cit., p. 130. 



DISLOCATIONS OF THE VERTEBRAE. bib 

The intervertebral disk seems habitually to disappear by softening 
and absorption ; and the ligaments undergo changes similar to those 
observed in other ligaments — that is, their torn portions reunite by 
cicatricial tissue or they contract new attachments in the evolution 
of the process of repair, and they may even become ossified. The 
tendency of the reparative process to end in suppuration, which has 
been observed to be exceptionally marked after fracture of the verte- 
bras, has been manifested also after dislocation, although possibly only 
in cases complicated by fracture. 

Etiology. The causes have been habitually described as direct and 
indirect violence and muscular action. The distinction between direct 
and indirect violence is made by classifying under the latter those cases 
in which the force has acted upon the column at some distance from 
the point of dislocation to bend it in one or another direction, and 
under the former those in which the force has acted directly upon the 
dislocated vertebra. But the mechanism — in most, if not in all cases 
— is certainly the same ; the column is forcibly bent, and the dislocation 
is produced by this forcible bending, just as a rod may be bent or broken 
by grasping and approximating its two ends with or without the aid of 
direct pressure against its centre. In the cases of dislocation by mus- 
cular action the cervical vertebras alone have been involved, and the 
movement has been that of exaggerated rotation or dorsal flexion. 

Symptoms and Diagnosis. Most of the symptoms of dislocation 
are the same as those of fracture of the vertebras. There is usually the 
same history of violence acting upon the spinal column, either directly 
or indirectly, to bend it beyond the limit of its normal range of motion, 
localized pain increased by movement or manipulation, inability to 
stand, partial or complete paralysis below the point of injury, diminu- 
tion or exaggeration of the normal mobility of the affected part, with 
or without reflex muscular rigidity of the upper segment of the column, 
and deformity recognizable by sight or touch. The symptoms which 
are thought to be of most service in establishing the differential diag- 
nosis between these two injuries are crepitus and abnormal mobility 
at the point of injury in fracture, and their absence in dislocation. 
Unfortunately, crepitus is not always obtainable in fracture by such 
manipulations as are permissible, and it may be present in dislocation 
accompanied by fracture — that is, in a condition in which the disloca- 
tion is the important injury, and the fracture a com pa rati vely unim- 
portant addition. Rigidity of the column at the injured point is 
common but not constant in dislocation, and it may be caused in frac- 
ture, or even in contusion or sprain, by muscular contraction. But 
while a positive differential diagnosis may not often be possible, a prob- 
able diagnosis may frequently be made, at least when the injury is in 
the cervical region, by attention to the attitude and rigidity of the 
neck, by recognition of the change in the relations of the transverse 
processes, or of the bodies of the vertebrae so far as they are accessible 
to examination in the pharynx, or of the lower spinous processes, and 
by the impossibility of correcting the displacement by pressure. 

On the other hand, muscular contraction and pain duo simply to 



516 DISLOCATIONS. 

bruising of muscles or nerves or to inflammation of the vertebral joints 
may produce an attitude and rigidity closely resembling those of dis- 
location. 

For the recognition of hsematomyelia — motor paralysis, thermo- 
anesthesia, and analgesia with preservation of tactile sensibility — see 
Chapter XL 

Deformity. The deformity consists in displacement of the spinous 
or transverse processes forward or backward or to one side, and 1 is to be 
recognized by palpation. The displacement of the transverse processes 
can be recognized by touch only in the neck, that of the spinous pro- 
cesses everywhere except in the upper cervical region unless the patient 
is very fat. The body of the displaced vertebra is accessible to exami- 
nation only in the pharynx and occasionally, as in a case reported by 
Dupuytren, by deep pressure through the anterior abdominal Avail. 

Pain, although sometimes absent, is commonly present, and is pro- 
voked or increased by movements of the body or by direct pressure 
upon the injured region. In some cases it is referred only to the point 
of injury, in others it is radiated along the course and over the region 
of distribution of the affected nerves. 

Paralysis, entirely absent in some cases, may be partial or com- 
plete within the affected region ; usually the two sides of the body are 
similarly affected (paraplegia), and limitation to a lateral half of the 
body (hemiplegia) is unknown except where the paralysis has been only 
partial. Motor paralysis is, as a rule, more marked and extensive than 
sensory paralysis. 

Paralysis has been observed in the muscles of the column adjoining 
the point of injury, in some or all of the parts of the body below the 
point of injury, and occasionally in those lying above it. The last- 
mentioned extension is to be explained by mechanical injury to the 
cord at a higher point than the dislocation, as by overstretching in 
diastasis, or by extravasation of blood, or by the extension of inflam- 
matory processes set up by the injury. 

Instead of paralysis, or in association with it, may be observed mus- 
cular contractions, neuralgic pains, and hyperesthesia, presumably de- 
pendent upon inflammatory changes in the cord and meninges. In a 
few cases there have been general convulsions, promptly followed by 
death. 

In addition to these symptoms of injury of the cerebro-spinal nerves 
and centres are others of widely different character and involving many 
different tissues and organs, which, as Hutchinson 1 has pointed out in 
a valuable and very interesting paper, may be referred to changes in 
the sympathetic, especially the vasomotor system. Thus, sudden rises 
of temperature, general or local and of longer or shorter duration, may 
be observed, sometimes associated with pallor of the surface or with 
marked pulsation in the arteries. If the injury is in the cervical region 
the heart-beat becomes slow but does not also show the intermissions 
that commonly accompany the slow pulse of injury to the brain. 

1 Hutchinson : London Hospital Eeport, 1866, vol. iii. p. 357. 



DISLOCATIONS OF THE VEBTEBRM 517 

Immobility of one or both pupils, with a slight degree of contrac- 
tion, has been noted ; in other cases immobility with dilatation. 

Priapism may accompany injury of the lower cervical and upper 
and middle dorsal regions when it is sufficient to cause paraplegia. 
Its frequency, compared with all cases in males, was found by Blasius 
to be 1 to 5 at the fourth cervical, 1 to 3.6 at the fifth, 1 to 2.7 at the 
sixth, and 1 to 2.5 at the seventh. He adds that it was present in 
fourteen out of twenty-five cases of fracture of the sixth cervical ver- 
tebra. The condition of the member appears, however, not always to 
be that of normal physiological erection, but rather of simple engorge- 
ment, the member remaining comparatively flaccid although swollen. 
In a few cases the priapism has been provoked only by the additional 
application of a local irritant, as the passage of a catheter. 

The rapid formation of bed-sores has also been attributed to vaso- 
motor or trophic changes, but while it is possible that such changes 
may act as a predisposing cause, yet the immediate, determining cause 
appears to be rather the prolonged, unrelieved pressure to which the 
parts are subjected in consequence of the paralysis. 

The occurrence of cystitis and ammoniacal decomposition of the 
urine within the bladder has also been explained in the same manner, 
but seems rather to be the consequence of over-distention of the bladder 
and of the use of the catheter. The later consequences of this cystitis 
are extremely serious and may hasten or be the immediate cause of 
death. 

Injury to or change in the vasomotor nerves has been thought to be 
the cause also of changes sometimes observed in the lungs. In two 
cases elsewhere mentioned I have known fracture of the cervical ver- 
tebrae to be followed by expectoration of blood coming from the lungs, 
and Blasius (following Moritz) describes a pulmonary congestion ap- 
pearing promptly, marked at first by increased secretion, and rapidly 
causing death by oedema of the lungs, usually on the second or third day. 

Prognosis. The injury is commonly deemed, and with good reason, 
one that places the life of the patient in great danger. Of the 278 
cases he collected Blasius collated 159 in which the diagnosis was cer- 
tain ; of these 36 recovered and 123 died, a proportion of 22.6 per 
cent, of recoveries, or 1 in 4.4. It is well worthy of note, also, that 
of these 36 recoveries the dislocation w T as completely reduced in 27 
and partly reduced in 2, and that all these 29 and 5 of the remaining 
7 were dislocations of the cervical vertebrae. 

In the fatal cases death usually followed promptly upon the receipt 
of the injury. Of 113 authentic cases more than half died within the 
first week, the others at varying periods up to five months. Death, 
especially in the cases in which it occurs promptly, is usually the con- 
sequence of the injury to the cord or of the inflammatory processes 
set up in it by the injury ; but even when such injury exists, especially 
if situated in the lower portion of the cord, life may be indefinitely pro- 
longed. Simple compression of the cord involves less danger to life 
than its complete or partial division or crushing, and relief of the com- 
pression may be followed by restoration of function. If the compres- 



518 DISLOCATIONS. 

sion takes place gradually, even to a very marked degree and at the 
upper end of the cord, as in several reported cases of cervical spinal 
caries, prolongation of life is still possible, and even marked and per- 
manent compression at the level of the atlas and axis has in two reported 
cases not proved immediately fatal. In one l of these, dislocation of 
the atlas forward from both the occiput and the axis with fracture of 
the odontoid process, the canal was reduced to a triangular slit two 
millimetres wide on one side and five on the other ; the patient survived 
five months, being completely paralyzed during most of the time. In 
the other case, 2 incomplete dislocation of the occiput from the atlas 
due to caries, the patient survived three months and died of tubercle 
of the brain. 

If the dislocation is reduced the symptoms may disappear promptly, 
or the paralysis may persist in whole or in part, and the case may even 
terminate fatally in consequence of the injury done to the cord or its 
envelopes. 

Treatment. This must be directed to the reduction of the disloca- 
tion, the prevention of its recurrence, and, if reduction is impossible, to 
the relief of the consequences of the displacement. If reduction is 
to be attempted it should be done promptly, and yet it must be added 
that it has been successfully made in several cases as late as the eighth 
or ninth day after the accident, and in one after the lapse of two 
months, and was followed by the prompt or gradual disappearance of 
the paralysis. 

The attempt to discriminate, with reference to the question of attempt- 
ing reduction, between cases in which the paralysis is due to simple 
compression of the cord and those in which it is due to its laceration 
or the effusion of blood within the canal is impracticable, because of 
the impossibility of making a positive differential diagnosis between 
those conditions. For the diagnosis of hsematomyelia see Chapter XI. 

The possibility that the attempt may cause the instant death of the 
patient, especially when the dislocation is in the upper part of the cer- 
vical spine, is a weighty factor in the problem, but should not, in my 
judgment, deter the surgeon if the patient or his friends accept the risk. 
It should only stimulate him to make the most accurate possible diag- 
nosis as regards the seat, direction, and mode of production of the 
dislocation, and most cautiously to select and execute the necessary 
manoeuvres. The urgency of the symptoms may leave him but scant 
time for observation and reflection, and the history of the case may 
throw no light upon the mode of production, so that the general rule 
to return the dislocated part along the path by which it escaped from 
its position cannot be knowingly and deliberately followed. Under 
such circumstances the surgeon must trust to traction aided by such 
flexion and rotation of the column as his best scrutiny of the displace- 
ment and knowledge of the relations of the articular processes may 
suggest. Anaesthesia should usually be employed. 

The return of the bone to its place is usually indicated by a distinct 

1 Costes: Schmidt's Jahrbiich., vol. Ixxix. p. 208. 

2 Darriste : Bull, de la Soc. Anatomique, 1838, vol. xiii. p. 144. 



DISLOCATIONS OF THE ATLAS. 519 

sound, and the rigidity which is usually present gives place to normal 
mobility. 

If the dislocation is comparatively slight, moderate lateral pressure 
may effect reduction, as in a remarkable case reported to Blasius 1 by 
Richter. A lad, eleven or twelve years old, consulted Richter because 
of deformity and stiffness of the neck caused by a fall. He found the 
spinous process of the third cervical vertebra slightly displaced to one 
side, and that pressure upon it caused pain. No paralysis. An attempt 
to reduce the dislocation by traction on the head failed, and the child 
was sent home to await another attempt. On the way, the child, who 
had heard and comprehended the diagnosis, stopped by a wall, leaned 
his head and shoulder against it, and pressed forcibly with the thumb 
against the opposite, convex side of the neck, and instantly reduced 
the dislocation. The story was confirmed by the child's companions, 
and the surgeon at his visit found the neck straight, normally movable, 
and free from pain. 

After reduction has been made no other retentive measures than rest 
in bed are ordinarily required, but if there is reason to fear recurrence 
the parts may be immobilized by gypsum bandages or padded wire 
splints that embrace the entire trunk if the injury is situated below 
the shoulders, and the head and chest if it is in the cervical region. 

If reduction cannot be made immobilization is still necessary to 
favor the formation of firm adhesions and the solidification of the 
bones in their new relations ; and in addition measures may be needed 
to meet the indications of other symptoms. Of the latter the most 
urgent is the acute hyperemia of the lungs that has occasionally been 
observed, and this is most promptly and satisfactorily met by free 
venesection. The need of regular catheterization in the paralytic cases 
must not be overlooked. Permanent drainage of the bladder through 
a perineal incision has been employed, apparently with advantage, in 
some cases. Suprapubic drainage would probably be preferable on the 
score of cleanliness and easy attention. 

DISLOCATIONS OF THE OCCIPUT AND CERVICAL VERTEBRA. 

Dislocations are far more frequent in this region than in the others. 
The fifth cervical vertebra is the one most frequently dislocated. The 
anatomical differences between the articulations of the atlas with the 
occiput and axis and those of the other vertebrae are such that a sepa- 
rate description of the injury at the upper end of this region is necessary. 

1. Dislocations of the Occiput (from the Atlas). 

The articulations between the atlas and the condyles of the occip- 
ital bone are formed on each side by a long, oval articular surface on 
the atlas, which is concave both from before backward and from side 
to side; the long axis of each runs from in front outward and back- 
ward and the outer margin of each is higher than the inner margin, so 
that each articular surface looks upward, inward, and backward, and 

1 Blasius: Loc. fit., vol. civ. p. 111. 



520 DISLOCATIONS. 

together they constitute a cup-shaped socket into which the rounded 
condyles of the occipital bone fit, and upon which they have a motion 
only of flexion and extension. In addition to the ligaments uniting 
the two bones there are other and strong ones within the canal which 
directly unite the posterior surface and apex of the odontoid process 
with the occipital bone and thus aid in opposing the separation of the 
atlas from the latter. 

The dislocation was formerly deemed quite a common one, and to 
this opinion succeeded another more in harmony with the anatomical 
conditions of the joint but still erroneous, namely, that it had never 
occurred. There are, however, three observations which positively 
demonstrate the occurrence of the injury, those of Costes, 1 Bouisson, 2 
and Milner. 3 In the former a lad fifteen years old was thrown down 
and beaten upon the back of the neck, by which the atlas was displaced 
forward from its articulations with both the occipital bone and the 
axis, and the odontoid, process of the latter was broken off. The 
patient's head remained inclined forward, and movements of the neck 
were difficult. A few days later hyperesthesia and paralysis of motion 
appeared, and persisted, without treatment, for four months ; then the 
right arm and leg became painful, and he was taken to the hospital. 
The pulse was feeble and slightly quickened ; at the posterior part of 
the neck was a firm swelling projecting a little on the right side which 
subsequently proved to be the posterior part of the axis, and the chin 
was turned to the left and so depressed as almost to touch the chest. 
He died thirty-six days after admission to the hospital. 

At the autopsy the skull was found dislocated backward from the 
atlas, the articular surfaces being completely separated on the right 
side, while on the left the anterior and inner part of the articular sur- 
face of the condyle was still in contact with the posterior part of that 
of the atlas. At the same time the atlas was tilted forward, rotated 
to the left in front and to the right behind, and displaced forward upon 
the axis ; the odontoid process was broken off at the base and reunited 
by fibrous tissue in an almost horizontal position with the body of the 
axis. The posterior arch of the atlas was so closely approximated to 
the body of the axis that the interval between them was reduced to a 
triangular slit five mm. wide on the left side and two mm. on the right. 

In the second and third cases the patients were instantly killed. 

The rarity of the occurrence is readily explained by the extent of 
the articular surfaces, the strength of the ligaments, and the extra- 
articular checks to the movement of the skull upon the atlas, the effect 
of which is to cause exaggerated movements of lateral or antero- 
posterior flexion of the head to be transmitted to the lower vertebrae. 

Treatment. If treatment is called for, the attempt to reduce should 

1 Costes : Schmidt's Jahrbiich., vol. lxxix. p. 208, and Malgaigne : Des Luxations, p. 329. 
Both these accounts are abstracts of the original report in the Journal de Bordeaux, 
August, 1852, and they differ materially from each other in some points. In the account 
here given I have in the main followed the former, since Malgaigne's appears to have 
been taken from an abstract, not from the original paper. 

2 Bouisson : Schmidt's Jahrbiich., vol. lxxxii. p. 216, from Bevue Med. Chirurg. de 
Paris, vol. ii. p. 355. 

3 Milner : St. Bartholomew's Hospital Beports, vol. x. p. 314. 



DISLOCATIONS OF THE ATLAS. 521 

be made by steady traction on the head combined with such coaptative 
pressure upon it aud the vertebrae as would be suggested by the char- 
acter of the displacement. 

2. Dislocations of the Atlas (from the Axis). 

The articulation between the atlas and axis is composed not only of 
the two lateral articulations as in the other vertebrae, but also of that 
between the odontoid process and the anterior arch of the atlas. This 
process, which, genetically, is the separated body of the atlas that has 
united with the axis, is placed vertically behind the anterior arch of 
the atlas, and is firmly held in place by the strong transverse ligament 
of the atlas, by the two alar or check ligaments which pass from the 
base of the process to the occipital bone at the margin of the foramen 
magnum, and by the vertical band of the transverse ligament, the 
suspensory ligament, and the posterior occipito-axial ligament which 
overlies the others. 

Dislocation forward or backward is possible only after fracture of the 
odontoid process or rupture of the transverse ligament, or by the slip- 
ping of the process beneath the ligament. The number of cases of the 
injury demonstrated by autopsy is fairly large and contains examples 
of all three forms. In most of the reported cases the injury was a 
diastasis or incomplete separation of the articular surfaces, the atlas 
being displaced forward, and usually so inclined that its anterior arch 
lay in front of the body of the axis. If, in this change of place, the 
odontoid process is broken off and accompanies the atlas, the proba- 
bility of dangerous compression of the cord is somewhat lessened. 
The other forms that have been demonstrated are dislocations forward 
and backward of both articular surfaces ; dislocation forward on one 
side only (unilateral dislocation forward) has been observed only clin- 
ically except in one case l in which there was also a similar dislocation 
of the sixth cervical. There is some reason to think that some of the 
obscure reported cases that ended in recovery may have been of the 
kind designated as " bilateral dislocation in opposite directions," that 
in which one articular surface is displaced forward and the opposite 
one backward, for experiment shows that this displacement can exist 
without causing compression of the medulla. A case observed by 
Sedillot probably was of this kind. ( Vide infra.) 

The following are examples of the rarer forms : 

Dislocation Forward without Rupture of the Transverse 
Ligament. A man 2 sixty years old fell from a height of four or five 
metres, striking upon his head, and survived ten hours. The head 
was held in moderate dorsal flexion, but was freely movable. The 
odontoid process had passed under the transverse ligament, and com- 
pressed the medulla. The right alar ligament was torn, the left 
untorn. The articular surfaces of the atlas had moved forward upon, 
but had not entirely left, those of the axis. There was no fracture. 

A similar case is reported by Orton, 3 in which all the ligaments 

1 Franchomme : Journ. des Sci. Mod. de Lille, May 29/1891, 

2 Journal de Chirurgie de Malgaigne, 1844, p. 370. 

3 Orton : Lancet, 1876, i. p. 853. 



522 DISLOCATIONS. 

uniting the axis to the atlas and occipital bone were torn, but the 
transverse ligament was uninjured, and the odontoid process lay behind 
it compressing the cord. The injury was caused by a blow of the fist 
received obliquely from behind, on the angle of the jaw. Death was 
instantaneous. These two are the only positive examples of this 
injury. 

Dislocation Backward. A woman 1 sixty-eight years of age fell 
while descending a ladder, struck upon her forehead, and died instantly. 
The atlas was dislocated backward on both sides, the anterior ligament 
detached, the capsular ligaments in front torn, the odontoid process 
broken at its base, and the posterior arch of the atlas broken on each 
side near the transverse process. The fracture of the atlas was thought 
to have been caused by its impact against the spinous process of the 
axis. 

There is no other reported case in which this variety has been 
demonstrated post mortem, but Malgaigne quotes from Ehrlich a sup- 
posed case which ended in recovery. 

Bilateral Dislocation in Opposite Directions. Sedillot 2 re- 
ported the case of a girl who had suffered for some time with stiffness 
of the neck and deviation of the head to the left, although it could be 
turned to the right. The injury had been caused by a man who seized 
her by the head from behind and forcibly twisted it to the side toward 
which it remained deviated. She died seven weeks later, with increas- 
ing paralysis. The autopsy revealed a " dislocation of the atlas," the 
details of which are not given. The front of the odontoid process was 
rough, and the odontoid ligaments were torn and partly destroyed, but 
there was no pus. Only the anterior portion of the cord was softened. 
Blasius describes this case as one of bilateral dislocation in opposite 
directions ; although it was probably such, the description does not 
prove it. 

In the commoner forms of diastasis with inclination and displace- 
ment of the atlas forward, and in complete forward dislocation the 
transverse ligament is ruptured, or the odontoid process is broken off 
and accompanies the atlas. In diastasis all the ligaments uniting the 
atlas to the axis are ruptured ; in dislocation forward the ligaments of 
the posterior arch are sometimes untorn. In a case reported by Philips, 3 
the posterior arch of the atlas was broken off on each side and remained 
in place, while the anterior portion, including the articular surfaces and 
carrying with it the fractured odontoid process, was displaced so far 
forward and downward that it lay entirely in front of, and became 
united to, the body of the axis. The patient survived forty-seven 
weeks and died of hydrothorax. The injury gave rise to no marked 
symptoms except persistent stiffness and pain in the neck, which were 
attributed during life to a strumous arthritis set up by the injury. 

I have met with no mention of injury to the vertebral arteries or 
veins. 

The spinal cord may be torn across in part or entirely, or crushed, 

1 Melchiori, quoted by Malgaigne, loc. cit., p. 333. 

2 Sedillot : Gazette Medieale, 1842, p. 776. 

3 Philips : Med.-Chirurg. Trans, vol. xx. p. 78. 



DISLOCATIONS OF THE ATLAS. 523 

or simply compressed. In double dislocation forward, it is most likely 
to escape injury if the odontoid process is broken off. On theoretical 
grounds, it is also thought not to be greatly endangered in bilateral 
dislocation in opposite directions. 

Cause. The cause has usually been a fall or blow upon the head. 
In forward dislocation, and in complete diastasis, the force has prob- 
ably always been so exerted as to bend the head toward the breast ; in 
partial diastasis, with rupture of the ligaments of only one side, the 
inclination must have been toward the opposite side. 

Unilateral dislocation or bilateral dislocation in opposite directions may 
be produced by exaggerated rotation of the head, as in Sedillot's case. 

Symptoms. In simple diastasis without displacement, and without 
injury of the cord, there may be no symptoms except pain and exag- 
gerated mobility of the head, and even the latter may be lacking because 
of spasmodic contraction of the muscles. In the common form, dislo- 
cation forward, the chin is depressed upon the chest, and a prominence 
may be felt at the back of the neck, below the occiput, formed by the 
spinous process of the axis. In the pharynx may be felt the project- 
ing anterior arch of the atlas. Pain is always present, and usually 
severe. Philips's case, above quoted, is a marked exception in respect 
of pain, disability, and deformity. The nervous symptoms vary with 
the degree of injury to the cord. 

Prognosis. The prognosis, even accepting the cases of doubtful diag- 
nosis followed by recovery, is very bad. Death may be caused imme- 
diately, or suddenly at a later period by the shifting of the loosened 
bones and the consequent compression of the cord, or by the progress 
of the changes induced by the primary traumatism. 

Treatment. Immediate reduction of the displacement and the pre- 
vention of its recurrence are imperative, if the former can be accom- 
plished without such violence as would in itself endanger the life of 
the patient. Although Philips's case furnishes proof that the persist- 
ence of the displacement is not necessarily incompatible with the pro- 
longation of life and activity, and although this proof is supported by 
the survival in fair condition of several other patients who have 
received injuries at the upper part of the cervical spine, the exact 
nature of which was in doubt, but which were followed by permanent 
rigidity and deformity of the part, yet there can be no -question, I 
think, of the propriety of making or even of the obligation to make, 
cautious, well-considered attempts to correct the displacement. Even 
if dangerous pressure upon the cord has not at the time taken place, 
yet it is certain that the condition is full of the gravest risk. The 
displacement may gradually increase, as in Dubreuil's case, in which 
the chin did not touch the chest until the tenth or eleventh day, and 
death occurred suddenly on the seventeenth, or the fatal increment ot' 
displacement may be suddenly added by the relaxation of the spas- 
modically contracted muscles, or by an incautious movement of the 
patient, or even of his attendants. This latter has occurred even after 
complete reduction, as in the following case, which I quote in some 
detail because it will illustrate many of the prominent features of the 
injury. 



524 DISLOCATIONS. 

A man l fifty-eight years of age fell down a hill-side and remained 
all night upon the ground unconscious. In the morning he tried to 
walk and found himself " unsteady." Help came, and he was taken 
home. When seen by the reporter he was seated in a chair, his chin 
resting on his sternum, his head and neck rigidly fixed. He was con- 
scious, not paralyzed, and complained of great pain in the neck. There 
was a marked prominence at the back of the neck below the occiput. 

By steady traction upon the sides of the head the displacement was 
completely reduced with a distinct snap and crepitus, and the pain was 
relieved. A week later he sat up in bed, and immediately fell back 
dead, with reproduction of the original deformity. 

The autopsy showed that the odontoid process had been broken off 
with a portion of the body of the axis, and displaced forward with the 
atlas (the transverse ligament remaining intact) so far that the lateral 
articular surfaces were almost entirely separated. 

As it seems probable from the shape of the bones that dislocation 
forward, except in cases that are immediately fatal, is very rarely 
complete, the traction upon the head should be directed somewhat 
backward, as well as upward, so as to avoid increase of the displace- 
ment, and may be combined with counter-pressure against the back of 
the neck. 

After reduction has been effected, and in cases of diastasis without 
displacement, the head and neck must be made immovable by suitable 
dressings. 

3. Dislocations of the Lower Six Cervical Vertebrae. 

These are by far the most common of the dislocations of the spine, 
and the articulations between the fourth and fifth and between the fifth 
and sixth are those most frequently affected. The varieties that have 
been observed and verified are diastasis, bilateral dislocation forward, 
backward, and in opposite directions, and unilateral forward. Of these 
the bilateral forward and backward may be classed as dislocations by 
flexion, and the bilateral in opposite directions and the unilateral for- 
ward as dislocations by abduction and rotation. The bilateral forward 
and the unilateral forward are the most common. The statistics of 
Blasius show that of 108 cases in which the exact nature of the injury 
w r as ascertained 23 were diastases, 41 bilateral dislocations forward, 37 
unilateral forward, 4 bilateral in opposite directions, and 3 bilateral 
backward ; to the latter may perhaps be added 8 others in which the 
diagnosis was not entirely beyond question. 

The positively demonstrated cases of bilateral dislocation 
backward are two reported by Porta and one by Stanley. The latter 
of the fifth cervical, in which the upper five vertebrae were firmly united 
to one another by bony fusion, has been quoted above, p. 496. The 
dislocation was complete, the body of the fifth vertebra resting upon 
the laminae and spinous process of the sixth. The injury was caused 
by a fall backward upon the head and back. Theoretically, it may be 
assumed that hyperflexion forward of a vertebra, combined with direct 

1 Gibson : Lancet, 1885, ii. p. 429. 



DISLOCATIONS OF THE CERVICAL VERTEBRAE. 525 

pressure backward upon it, would produce this form of dislocation, for 
by the flexion a diastasis would be effected in which the posterior and 
capsular ligaments would be torn, and then the direct pressure back- 
ward would rupture the intervertebral disk and produce the displace- 
ment. That the injury is rare notwithstanding the frequency of the 
occasions in which the head is bent forcibly forward is to be explained 
by the normal freedom of motion in this direction which allows the 
chin to be depressed upon the breast. 

Of the four cases of bilateral dislocation in opposite direc- 
tions I have been able to examine the original reports in none. Possibly 
the one attributed to Malgaigne l is the same as the case described in 
his Luxations, p. 371, as unilateral forward ; if so, and if it is retained 
in the list, it would seem proper also to add Martelliere's case mentioned 
by Malgaigne upon the following page, 372, as resembling his own in 
the associated slight displacement backward of the opposite inferior 
articular process with rupture of the capsule. In Malgaigne's case 
there was also chipping of the lower border of the articular surface of 
the dislocated vertebra on the side of the principal dislocation with the 
production of a notch in which the upper edge of the underlying pro- 
cess was engaged. Similar chipping of the same border was found in 
Martelliere's case, but the articular process had passed completely 
beyond the underlying one and had descended in front of it to a dis- 
tance of nearly one-quarter of an inch. This form is an exaggeration 
of the unilateral dislocation forward, and their causes and mode of 
production will, therefore, be considered together. 

In bilateral dislocation forward both inferior articular sur- 
faces of the dislocated vertebra are carried forward beyond the anterior 
borders of the underlying ones, and the fixation is effected either by 
the dropping of the processes into the notches in front of the latter, or, 
if the movement forward is combined with anterior flexion, by the 
interlocking of the body of the upper vertebra with the projecting 
lateral borders of the upper surface of the one beneath. Blasius claims 
that this is effected almost as frequently by posterior as by anterior 
flexion, an opinion which it is not easy to accept. 

In hyperflexion forward the fulcrum is found at the anterior border 
of the body of the vertebra, and the first effect is to produce diastasis 
with rupture of the posterior and capsular ligaments, and then as the 
projecting lip on the inferior anterior border of the body of the upper 
vertebra engages in front of the upper border of the loAver one, and 
the force continues to act, not simply to flex but also to crowd the head 
directly down toward the chest, the body of the upper vertebra slips 
downward and forward, by which movement the articular surfaces are 
separated antero-posteriorly. Then if the neck is straightened the 
body of the vertebra may be raised to its original level, and yet the 
dislocation will be maintained by interlocking of the articular pro- 
cesses. Under such circumstances there would be no angle in the 
direction of the neck, but only a depression in the nape and a projec- 
tion in the pharynx corresponding to the body of the dislocated vertebra. 

Occasionally the spinous process with more or less of the adjoining 

1 Malgaigne: Revue Mod. Chirurg., 1853. 



526 



DISLOCATIONS. 



laminae is broken off. The intervertebral disk is always torn, and so 
are usually the ligamenta flava and the interspinous ligament; the 
longitudinal (anterior and posterior) ligaments are less frequently torn, 
often only stripped off. The spinal cord may be compressed or crushed 
or stretched, or may escape injury. 

As the articular surfaces are in some cases almost horizontal, it is 
conceivable that the dislocation may be produced by direct violence 
acting upon the bone from behind forward, without the aid of either 
ventral or dorsal flexion of the column. 

In unilateral dislocation forward r (dislocation by abduction 
and rotation) the articular surface on one side of the upper vertebra is 
carried upward and forward until its posterior edge has passed the 
anterior edge of the one with which it articulates. At the same time 
the spinous process moves from the median line toward the side of the 
dislocation, and the anterior surface of the body projects slightly in 



Fig. 273. 



Fig. 274. 





Dislocation of the neck by flexion; 
median section. 



Bilateral dislocation by flexion ; fourth cervical 
vertebra; from behind. (Malgaigne.) 



front of that of the underlying one. In short, the movement is one of 
rotation and abduction about the opposite articular surface as a centre, 
and by it the vertebral canal is but slightly narrowed, and but little or 
no violence is done to the cord. The segment of the column above the 
dislocation is abducted, and forms with the lower part an angle or curve, 
the convexity of which is on the dislocated side. 

The normal motion in the articulations of this region is one of rota- 
tion and abduction. The dislocation is produced by carrying the move- 

1 Blasius doc. cit., vol. civ. p. 82) found only one case of unilateral dislocation backward 
—of the sixth cervical— and even in it there was also fracture of the lamina and body 
of the seventh vertebra on the side of the dislocation. 



DISLOCATIONS OF THE CERVICAL VEBTEBBJE. 527 

merit beyond its normal limits, by any force which over-abducts or 
over-rotates the upper part of the column. This force may be an 
external one, or one developed by the muscles attached to the head. 
Of these dislocations by muscular action Volker 1 collected fourteen 
more or less certain cases, and made them the basis of a careful study 
of the subject. Additional cases have since been reported. The move- 
ment which produces the lesions is a sudden turn of the head to one 
side ; if it is violent, ill regulated, if its momentum is unchecked by 
the antagonistic muscles, it carries the head beyond its normal limit, 
and produces the dislocation in exactly the same manner as if an ex- 
ternal force had been applied to the head to turn it in the same direc- 
tion. 

Fig. 275. 




Complete unilateral dislocation by rotation or abduction. 

In diastasis the lesion consists essentially of more or less extensive 
rupture of the ligaments. It is the same in its forms, nature, and 
etiology as the other varieties, with the exception of the persistent dis- 
placement of the bones and of the change in the relations of the artic- 
ular surfaces to each other; the displacement is either entirely absent 
or is slight. A singular instance of the production of a diastasis by 
muscular action is reported by Lasalle : 2 a crazy man, confined in a 
strait-jacket in a chair, jerked his head violently backward and for- 
ward, became at once paralyzed, and died a few hours later. The 
autopsy disclosed a separation between the fifth and sixth cervical ver- 
tebrae, with rupture of the posterior ligament, the interspinous muscles, 
the ligamenta flava, and the intervertebral disk. The possible produc- 
tion of hsematomyelia is to be borne in mind. 

Symptoms. Unilateral dislocation forward. The posture of the head 
has varied so greatly in the reported cases that it is of no value as a 
symptom. Not only may the abduction of the upper segment of the 
column, which is necessary to the production of the dislocation, be 
almost entirely corrected by the sinking back of the articular process 
of the upper vertebra into the notch of the lower one, but even it' it 
persists it may be so far compensated for or obscured by flexion in the 
occipito-atloid and rotation in the atlo-axoid articulation, that it will 
not be recognized. The face is, however, usually turned away from 
the side on which the dislocation has taken place. A painful promi- 
nence, swelling, or rounding can be recognized on the dislocated side : 

1 Volker: Deutsche Zeitschrift fur Chir., 18?b\ vol. vi. p, 124. 

2 Lasalle: Gaz. Modieale, 1841, p. 7(53. 



528 



DISLOCATIONS. 



it is due, according to Volker, to the angle created in the column, the 
slight projection of the transverse process, and the contracted condition 
of the muscles. Observers differ as to the condition of the muscles on 
the opposite side, some reporting them relaxed, others contracted. The 
deviation of the spinous process of the dislocated vertebra to the side 
of the dislocation is a valuable sign when it can be recognized, but the 
depth at which the third, fourth, and fifth spinous processes are placed 
is such that their position cannot usually be determined, and while that 
of the second can always be felt, its deviation may be unrecognizable, 
because the position of the underlying ones with which it must be com- 
pared remains unknown. The projection of the body of the vertebra 
in the pharynx is sometimes recognizable by the finger introduced 
through the mouth. 

The last named three signs are diagnostic if fracture can be excluded, 
but as the last two are unrecognizable in many cases, the first, the 
existence of a painful prominence on the side of the neck, is the one 
upon which the surgeon will usually have to depend. 

Cases may occur, as they have occurred, in which the symptoms are 

so obscure that a diagnosis be- 
Fig. 276. tween dislocation by muscular 

action and muscular rheumatism 
cannot be positively made. Un- 
der such circumstances the manip- 
ulations that would reduce a dis- 
location if it were present should 
be carefully made. If they re- 
duce the deformity and relieve 
the symptoms they both establish 
the diagnosis and cure the patient. 
In bilateral dislocation forward 
the symptoms vary greatly. The 
head may be bent far forward 
toward the chest with marked 
prominence in the nape of the 
neck of the spinous process of 
the vertebra next below the dis- 
located one, or it may be bent 
backward or backward and to one 
side, with marked projection of 
the trachea and perhaps larynx, 
and irregularity in the outline of 
the front of the column recogniz- 
able by palpation through the soft 
parts. The head may be rigidly 
fixed, or, more rarely, freely mov- 
able. These differences depend 
partly on the position of the dis- 
located bone, the presence or 
absence of associated fracture, and the extent of the injury to the con- 
necting ligaments, partly on the direction and character of the dislocat- 







Bilateral dislocation forward of the fifth cer 
vical vertebra. (From a photograph.) 



DISLOCATIONS OF THE CERVICAL VEBTEBBM 529 

ing force, and partly on the contraction or relaxation of the muscles 
which control the position taken by the unaffected joints above the seat 
of injury. In the majority of cases the head is bent forward, and an 
angle with its apex directed backward is formed by the two segments 
above and below the dislocation. Attempts to move the head and 
pressure at the seat of injury are very painful. In these patients the 
irregularity in the line of the transverse processes may sometimes be 
recognized by the touch ; and if the dislocation is not too low the pro- 
jection of the body of the vertebra may be felt in the pharynx. 

Of the symptoms of bilateral dislocation backward nothing positive 
can be said. In most of the supposed cases the head has been bent 
backward, the face directed somewhat upward, the tissues of the front 
of the neck tense, and respiration and deglutition somewhat interfered 
with. 

In bilateral dislocation in opposite directions it seems probable that 
the head would be fixed in rotation, but possibly not abducted. 

Paralysis, partial or complete, is frequently observed. Its immediate 
importance, its urgency, as a symptom varies accordingly as the dislo- 
cated joint is above or below the point of exit of the phrenic nerve. 
The fourth cervical nerve, from which the phrenic mainly arises, 
though it receives a branch also from the third or fifth, leaves the ver- 
tebral canal through the foramen between the third and fourth verte- 
brae, but leaves the side of the cord at a somewhat higher point. A 
dislocation below the third cervical vertebra may cause paralysis of all 
the accessory muscles of respiration that act by raising the ribs, but, 
the diaphragm continuing to act, prolongation of life is possible. If, 
on the other hand, the dislocation is at a higher point, and the trunks 
going to form the phrenic nerve are injured or the cord is so compressed 
or torn that the integrity of the corresponding fibres within it is de- 
stroyed, or they are all cut off from the respiratory centre, then the 
diaphragm also, being no longer innervated by these nerves, immedi- 
ately ceases to act, and the individual dies asphyxiated. In a few cases 
the threatening symptoms have been instantly relieved by changing 
the position of the patient or by systematic reduction of the disloca- 
tion. In all such threatening cases and in those that are immediately 
fatal the injury is, as a rule, at one of the upper joints. In the ex- 
ceptions there have been associated injuries to which the death is to be 
attributed. 

If the paralysis is due to compression or laceration of the cord it 
may be complete of both motion and sensation below the point ol 
injury, or it may involve only the motor nerves. It seems probable 
that the partial paralyses are due to pressure not upon the cord but 
upon a nerve trunk in the intervertebral foramen. (See also Hsema- 
tomyelia, in Chapter XI.) 

Loss of control over the sphincters, incontinence of urine, and the 
other secondary symptoms of injury to the cord have been already 
considered. 

Prognosis. The mortality of dislocations of the lower six cervical 

vertebrae, excluding cases of diastasis, cannot be positively determined 

because of the uncertainty of the diagnosis in cases that recover ; it is 
34 " to 



530 DISLOCATIONS. 

highest, probably 75 per cent,, in bilateral dislocation forward, and 
much less in the unilateral. In the fatal cases death, as a rule, conies 
promptly, within the first week. Suppuration has been observed about 
the seat of injury in cases that remained unreduced. In a number of 
cases gradual improvement has taken place in the attitude and mobility 
of the neck. In one reported by "Walton l of supposed dislocation of 
the third cervical forward the symptoms did not become marked until 
two months after the accident and then increased to complete helpless- 
ness ; fifteen months after the accident they suddenly improved, and a 
month later recovery was complete. 

Treatment. In unilateral dislocation forward, at least in those pro- 
duced by muscular action, Volker says reduction is usually easy and 
free from danger. Mention has been made above of the case in which 
a boy reduced his own dislocation by resting his head and shoulder 
against a wall and pressing upon the prominence in the neck with his 
thumb. 

Simple traction upon the head, the counter-extension being made by 
the weight of the body, followed by rotation of the face toward the 
dislocated side has proved successful, but it seems better and is gener- 
ally recommended that the articular process should be freed by still 
further abducting the head and upper segment of the column (away 
from the side of the dislocation), and then, when freed, should be 
rotated backward into place. If traction is used it should be made in 
the direction of the long axis of the upper segment, not in that of the 
lower one, for in the latter case the strain would come wholly or mainly 
upon the untorn connections on the non-dislocated side and rather tend 
to depress the dislocated articular process still further in front of the 
corresponding lower one than to raise it above it. 

Bilateral dislocations in opposite directions are to be classed with the 
preceding as dislocations by abduction and rotation, and treated in the 
same manner. Probably the differential diagnosis could not be made 
clinically. 

In bilateral dislocations forward the methods that have been employed 
with success have combined traction upon the head, either in the sitting 
or recumbent posture, with pressure upon the front and back of the 
neck at suitable points. 

After reduction the patient should be kept quiet for some time, and 
if reproduction of the dislocation is feared a retentive dressing should 
be applied. It must be rigid enough to prevent any flexion of the 
neck forward or backward, and, after unilateral dislocation, should 
include the head so as to prevent rotation. Such a dressing can be 
conveniently made with plaster of Paris. 

DISLOCATIONS OF THE DORSAL VERTEBRJE. 

The cartilaginous surfaces of the articular processes in the dorsal 
region are placed more nearly in a vertical plane than those of the 
cervical vertebrae ; the superior ones look backward and slightly up- 
ward and outward, the inferior ones, with the exception of those of 

1 Walton : Boston Medical and Surgical Journal, March 21, 1889. 






DISLOCATIONS OF THE DORSAL VERTEBBM 531 

the twelfth, look forward and slightly downward and inward ; the inte- 
rior ones of the twelfth are placed like those of the lumbar vertebne 
and look outward and somewhat forward. This disposition does not 
in itself make dislocation to either side by rotation or direct disloca- 
tion backward with fracture difficult ; dislocation forward is made pos- 
sible by flexion sufficient to raise the inferior articular processes of the 
upper vertebrae above the superior ones of the lower. Dislocation 
between the twelfth dorsal and first lumbar vertebrae seems to be much 
less favored by the relations of the processes, and yet this is the point 
in the combined dorsal and lumbar regions where dislocation is by far 
most common. Blasius l collected twenty-two cases in which the char- 
acter of the dislocation was demonstrated by autopsy ; of these one was 
of the third dorsal vertebra, three of the fifth, one of the sixth, one of 
the ninth, three of the tenth, two of the eleventh, and eleven of the 
twelfth ; of the doubtful cases ten were thought to be of the twelfth, 
four of the eleventh, and one each of the fifth, eighth, and tenth. 

The observed varieties are the bilateral forward and backward with 
about equal frequency, the bilateral in opposite directions, and the 
lateral. Of the latter there are only two demonstrated cases, Bell and 
Mohren stein, twelfth dorsal, and even in these Blasius thinks the injury 
was primarily a unilateral dislocation forward or backward, which was 
followed by bodily lateral displacement. In the few cases in which 
the condition of the adjoining ribs is noted, these have been found 
sometimes dislocated and sometimes fractured not far from the column. 
The degree of injury to the cord varies with the character and extent 
of the displacement. Other pathological conditions have been consid- 
ered above. 

Causes. The causes have been forcible flexion of the trunk forward 
and the direct action of great violence upon the back or side of the 
spinal column, as in the fall of a heavy object, or the passage of the 
wheel of a wagon across the body. 

Symptoms. The symptoms of the dislocation are found in recog- 
nizable changes in the position and relations of the dislocated vertebrae, 
especially in the prominence of its spinous processor of the underlying 
one, or in its lateral displacement, and in a deviation of the column 
which creates an angle at the seat of the dislocation, the apex of which 
is usually directed backward. In some cases it is noted that the artic- 
ular processes of one or the other of the two adjoining vertebrae form 
prominences under the skin. 

Excessive mobility at the seat of dislocation has also been observed 
in most cases. 

Paralysis appears to be more common and more complete in the for- 
ward than in the backward dislocations, and in a few cases lias disap- 
peared after reduction. 

The symptoms resemble so closely those of fracture that the differ- 
ential diagnosis, in the absence of post-mortem examination, can rarely 
be made with certainty. The failure to obtain crepitus is no proof of 
the absence of fracture, and when present it may be due to the presence 
of an associated unimportant fracture. Reduction and the absence of 

1 Blasius: Loc. cit., vol. ciii. p. 46. 



532 DISLOCATIONS. 

a tendency to reproduction of the deformity are the best obtainable 
evidence that the injury was a dislocation. 

Prognosis. The prognosis, as regards either the preservation of life 
or the full restoration of function, is not favorable. The uncertainty 
of the diagnosis in most cases of survival and the comparative few- 
ness of the cases deprive the percentages of value, and it can only 
be said that the injury seems more likely to prove fatal when it is 
situated in the upper part of the region than when in the lower, and 
that in quite a number of cases more or less complete recovery has 
followed. 

Treatment. Reduction, by extension and counter-extension at the 
hip and shoulders, has been tried, and sometimes with success. If it 
is obtained the patient must be kept absolutely recumbent for several 
weeks, and preferably with the trunk enveloped in a plaster-of-Paris 
dressing, and the same measures should be employed even when reduc- 
tion has not been effected, in order to favor the consolidation of the 
bones in their new positions. 

DISLOCATIONS OF THE LUMBAR VERTEBRA. 

The possibility of the occurrence of pare dislocation of the lumbar 
vertebra?, which has been long in doubt because of the close interlock- 
ing of the processes and the strength of the ligaments, is proved by 
two cases collected by Blasius and also, it may be said, by two others 
in which there was present associated but unimportant fracture of 
some of the processes. The first two cases are those of Curling x and 
Porta. 2 

Curling presented a specimen preserved in the London Hospital 
Museum : the intervertebral disk between the third and fourth lum- 
bar vertebrae was destroyed, with slight splintering of the edge of the 
bone at one or two places ; the body of the third projected nearly 
half an inch in front of that of the fourth, and the articular processes 
of the two bones were separated to the same distance ; the ligaments 
connecting the laminae and the spinous processes were stretched but 
not materially torn. 

The other two cases are those of Keig 3 and Cloquet. 4 In the 
former a sailor twenty-three years old was crushed under a heavy iron 
cylinder which fell across his back. The second lumbar vertebra was 
displaced backward seven lines, the upper articular process of the third 
becoming lodged in the notch of the second ; the tip of the right lower 
articular process of the second was broken off but not separated from 
the rest ; the left transverse processes of the first and second vertebrae 
w T ere broken off (by muscular action, it was thought), and the spinous 
processes of the ninth, tenth, and eleventh dorsal vertebrae and the 
left eleventh and twelfth ribs were broken. The right sacro-lumbalis 
muscle was completely divided transversely, and the liver and spleen 
were ruptured. 

1 Curling: London Hospital Reports, vol. iii. p. 355. 

2 Quoted by Blasius : Loc. cit., vol. ciii. p. 55. 

3 Keig : Schmidt's Jahrbuch., vol. cvii. p. 69. (Blasius writes the name Keli.) 

4 Blasius : Loc. cit., from Journal des Difforniites, vol. i. p. 453. 



DISLOCATIONS OF THE LUMBAR VERTEBRAE. 533 

In another case Porta found at the autopsy a pure diastasis between 
the third and fourth lumbar vertebrae, the bones being separated a few- 
lines without lateral or antero-posterior displacement, and all the liga- 
ments being torn ; the spinous process of the third was broken at its 
base. 

The conditions which so effectually oppose dislocation with or with- 
out fracture are the great breadth, thickness, and elasticity of the 
intervertebral disks, the large masses of muscle that lie on each side 
of the spinous processes, and the arrangement of the articular pro- 
cesses by which those of each upper vertebra are received between 
those of the next lower and are thus absolutely prevented from mov- 
ing laterally or from being separated by lateral flexion without fracture 
of one or the other. 

Symptoms. The symptoms are irregularity in the line of the spinous 
processes, local pain, disability, and more or less complete paralysis of 
the parts below. As the spinal cord is replaced throughout the greater 
part of this section by nerve trunks, the cauda equina, which less 
completely fill the canal, the paralysis is less likely to be complete than 
Avhen the injury is at a higher point, and it is also more easily recov- 
ered from if the displacement is corrected. 

Prognosis. The prognosis is more favorable than in dislocations of 
the dorsal and cervical regions, presumably because of the usual 
absence of injury to the cord, and the less extent of the paralysis ; and, 
while many of the cases have promptly proved fatal, death has usually 
been due to associated injuries. 

Treatment. In backward dislocation reduction appears not to have 
been difficult ; it has been obtained by pressure upon the projecting 
spinous process, with or without forcible extension of the column. In 
a case reported by Harrison, 1 dislocation backward of the third 
lumbar vertebra, reduction was obtained with the aid of anaesthesia by 
extension and counter-extension, combined with moderate pressure 
upon the spinous process, while the patient was lying upon his back. 
The paralysis began to diminish on the following day, and complete 
recovery followed, although a slight projection in the line of the column 
persisted. A plaster-of-Paris jacket was worn for four and a half 
months. 

Possibly the plan recommended by some of the older surgeons, of 
combining flexion forward with traction, would be necessary or useful 
in some cases. It could be effected by placing the patient on his belly 
across the side of a barrel, or by raising; him on a cloth passed under 
his oeny. 

1 Harrison : Lancet, 1885, ii. p. 114. 



CHAPTEK XXXIX. 

DISLOCATIONS OF THE STERNUM. 

(See also Fractures of the Sternum.) 

Under this title are included only dislocations of the normal 
divisions of the sternum from one another, not those of the sternum 
from the clavicles or from the cartilages of the ribs ; they are those of 
the body from the manubrium, and of the ensiform process from the 
body. 

Dislocations of the Body from the Manubrium. 

The manubrium, constituting nearly the upper third of the sternum, 
is united to the second piece, the body, by a layer of interposed carti- 
lage, sometimes hyaline, sometimes more or less distinctly fibrous, 
and sometimes containing a central synovial sac. Henle speaks of 
this central sac as of rare occurrence ; Maisonneuve and Brinton found 
it in about two-thirds of the cases examined. Ossification of the band 
occasionally takes place in advanced life ; the earliest age at which it 
has been observed is thirty-four years. 

The second costal cartilage articulates with both these segments of the 
sternum at their junction. Although this division of the sternum into 
segments was described by the anatomists, no account thereof appears to 
have been taken by surgeons until, in 1842, Maisonneuve 1 read before 
the Academie de Medecine in Paris a paper in which he called attention 
to the anatomical divisions of this bone, and reported two cases of dislo- 
cation of the body from the manubrium which had come under his 
observation, and in which he had made the autopsies. Earlier records 
show several cases which were doubtless dislocations, but Maisonneuve 
w T as the first to separate them from the class of fractures and apply this 
name to them. 

The injury is not a common one, even if allowance is made for the 
probable description of some as fractures. Malgaigne, in 1855, could 
collect only ten examples, although he included in the list several of 
the older cases reported as fractures; Anceiet 2 collected sixteen cases 
of all kinds, Brinton 3 thirteen of dislocation forward, and added one 
of his own. Gurlt, 4 in his table of fractures and disastases of the ster- 
num, has twenty-nine cases classified as diastasis between the first and 
second pieces, and three between the second and third. Adding to 
these those quoted by Anceiet, Brinton, and Servier, 5 the list is increased 
to more than forty. Only one of the patients was a woman, and the 
ages ranged from thirteen to more than sixty-five years. 

1 Maisonneuve : Arch. gen. de Med., 1843, vol. xiv. p. 249. 

2 Anceiet : Gazette des Hopitaux, 1863, p. 257. 

3 Brinton : American Journal of the Medical Sciences, July, 1867, p. 39. 

4 Gurlt: Die Knochenbniche, 1862, vol. ii. p. 31. 

5 Servier ; Diet. Encyclopedique, 1884, art. Sternum. 

534 



DISLOCATIONS OF THE STERNUM. 535 

In sixteen the body was completely dislocated forward and upward 
upon the manubrium, in three or four backward ; in two the dislocation 
was incomplete forward, and in oue the two segments were separated 
longitudinally. 

Causes. The injury has been produced by direct and indirect vio- 
lence, and, possibly, in one or two cases, by muscular action. Guines, 1 
in the report of a case of tetanus in a boy thirteen years old, states 
that on the seventh day he found the breast elevated, all the false ribs 
displaced and carried upward, the sternum bent at the junction of the 
first and second pieces, and forming with the ensiform process an 
eminence three inches high. The pectoral muscles were forcibly con- 
tracted, while those of the abdomen were, if not in their natural condi- 
tion, at least much relaxed (compared with their previous condition). 
On the eighteenth day, the tetanus having ceased, it is noted that the 
deformity of the breast persisted. I understand this to mean that 
there was an angular displacement at the junction of the first and 
second pieces, the apex being directed backward, and the ensiform 
process distant three inches further than usual from the spine. 

In two other cases muscular action may possibly have been the 
determining cause, but the mode of production is obscure ; in one of 
them (Drache, quoted by Malgaigne), a young man fell into a cellar 
with some falling timber, which rested upon his chest ; while striving 
to free himself he felt a snap in the region of the sternum, and the 
dislocation was thought to have been then produced. In the other 
(Ancelet), a boy thirteen years old was exercising on parallel bars with 
his chest bent forward ; his feet unexpectedly touched the ground, and 
a forward dislocation, complete on only the left side, was produced. 

In the case of longitudinal separation (Aurran and David), the 
patient fell from a height of fifty feet, striking on his back across a 
low wall so that his head was on one side and his legs on the other. 
He received at the same time a fracture of the spinous processes of the 
last two dorsal vertebrae, and the dislocation (a diastasis) seems, there- 
fore, to have been produced by hyper-dorsal flexion of the spinal col- 
umn, by which the two segments of the sternum were pulled apart. 
The case seems, to some extent, to confirm the theory of the possibility 
of dislocation by muscular action. The patient recovered. 

In three cases a forward dislocation was caused by violence received 
directly upon the front of the chest, presumably upon the manubrium. 
One patient (Aurran) fell with a ladder, striking his chest against one 
of the rungs ; another (Malgaigne) fell against the gunwale of a boat ; 
the third (Fremey 2 ) was struck and killed by the pole of a wagon. 
Drache's case also is sometimes quoted as an example of direct vio- 
lence, and so perhaps may be Richet's, 3 in which some boxes of soap 
fell upon a man, and caused a dislocation backward of the body upon 
the manubrium. Reid's patient was kicked by a mule ; the direction 
of the displacement is not mentioned. 

In DuverneyV patient the injury was compound, and was caused 

1 Guines: Arch. gen. de Med., 1829, vol. xix. p. 396. 

' z Fremey : Bull, de la See. Anatoinique, 1868, vol. xiii. p. 419. 

3 Rictiet, reported by Siredy in Bull, de la Soe. Anat., 1857, vol. ii. p. 305. 

1 Duverney : Maladies des Os, 1751, vol. i. p. 235. 



536 DISLOCATIONS. 

by the forcible compression of the sides of the chest by a falling stone, 
the second piece being thrust forward (see Fractures, p. 175); and in 
Pitha's l it was caused by similar lateral compression between the buffers 
of two railway cars. 

In most of the others the injury was caused by a fall from a height, 
by which the trunk was probably bent forcibly forward, as shown in 
several of them by associated fracture of the cervical or dorsal verte- 
bra?. The mode of production in these cases appears to be similar to 
that by lateral compression of the ribs ; the first and second ribs being 
shorter and more rigid than the others, the manubrium remains fixed, 
while the second piece is pushed forward and upward by the other ribs 
that articulate with it and which are themselves pressed forward by 
the flexion of the . spine. Servier demonstrated this action upon the 
cadaver by exposing the sternum and costal cartilages, dividing the 
third, fourth, and fifth of the latter, and then throwing the body back- 
ward from a sitting position so as to strike upon its shoulders on the 
floor ; the ends of the ribs could be seen to spring forward and inward. 

Pathology. In the common form, dislocations of the second piece 
forward and upward, the bones override, sometimes as much as an 
inch ; the anterior fibrous layer lining the bone is torn, the posterior 
one stripped from the second piece. The second costal cartilages almost 
invariably remain in contact with the manubrium. Sometimes the 
third and fourth have been broken. 

In two cases, Nekton's and Ancelet's, the dislocation was incom- 
plete ; in the latter the body was turned about its longitudinal axis 
so that its left upper corner was elevated above the manubrium and 
the second costal cartilage to a distance fully equal to the thickness of 
the bone, while its right upper corner remained in place. 

The dislocations of the body backward furnish two autopsies. Saba- 
tier's 2 patient was an elderly man who, after having been beaten with 
the fists, was thrown into a ditch thirty feet deep ; he survived for a 
week. The body of the sternum was displaced 2.8 cm. upward behind 
the manubrium ; there was a large extravasation of blood under the 
skin and in the substance of the right lung, which was extensively 
bound down by old adhesions. 

Richet's patient, twenty-seven years old, was thrown down upon his 
back by some heavy boxes that fell from a wagon upon his chest and 
caused many associated injuries ; he died of pyasmia on the twenty- 
second day. The body of the sternum was displaced backAvard and 
slightly upward behind the manubrium ; the second costal cartilage on 
the left side remained attached to the body, that of the right side was 
separated from both body and manubrium, and its end was free in an 
abscess that bathed the dislocation. There was a complete transverse 
fracture of the manubrium half an inch above its lower end, and a 
fracture of the body without displacement at the level of the articula- 
tion of the fourth costal cartilages. There was a compound fracture 
of the left leg, and simple fractures of the left third and fourth ribs 
and of the right radius. 

The complications have been numerous and varied : fractures of the 

1 Gurlt : Loc. cit,, p. 225. 2 Gurlt : Loc. cit., p. 275. 



DISLOCATIONS OF THE STERNUM. 537 

cervical and dorsal vertebra?, of the ribs and costal cartilages, rupture 
of the adherent lung, rupture of the lungs and heart (Duverney). 

Symptoms. In the severe cases — those complicated by other injuries, 
especially of the spinal column and thoracic viscera — the general symp- 
toms due to the dislocation may be masked or increased by those of 
the other lesions ; in general terms, the rational symptoms in forward 
dislocation are more or less transient oppression of breathing and sharp 
pain at the seat of injury, increased by pressure or by movements of the 
body or head. 

The neck and trunk are bent forward, the lower ribs appear promi- 
nent, and the upper ones depressed. The anterior surface of the ster- 
num presents a well-marked elevation at the level of or just below the 
first intercostal space, which has a sharp, well-defined upper margin 
rising directly from the manubrium and is continuous below with the 
body of the sternum. The absence of the second costal cartilages 
from the upper corners of the body makes it possible to recognize with 
the finger the shallow, saucer-like depression at these points with which 
they articulate. The recognition of these depressions, or the distance 
of the upper edge of the projection from the line of the third ribs, 
will enable the surgeon to distinguish a dislocation from a fracture of 
the body ; and the presence of the second costal cartilages below the 
upper edge of the projection will indicate a fracture of the manubrium. 

Prognosis. The prognosis is grave ; more than half the patients have 
died of their injuries, though doubtless the fatal result is to be attrib- 
uted in most of the cases to the associated lesions. In the cases that 
have survived a failure to effect reduction has not led to any disability ; 
one of the patients in the list had borne his unreduced dislocation for 
fifteen years without inconvenience. Stetter 1 mentions, without giving 
the reference, a case observed by Audic of habitual dislocation back- 
ward (or of the manubrium forward) which recurred every time the 
patient rose from the recumbent posture without supporting his head. 

Treatment. Reduction is to be made by bending the trunk backward 
and making pressure upon the projecting piece of the sternum. The 
patient should be placed upon his back on a firm cushion or on a table 
with his head and shoulders projecting beyond its end, and then the 
head and neck should be drawn backward, and counter-extension made 
on the pelvis. It is recommended also that in dislocation backward 
the patient should be encouraged to make full inspirations. 

After reduction is made a body bandage, or, better, a broad strip of 
adhesive plaster, should be placed around the chest. 

In case of failure to reduce by these or other simple means, resort 
should not be had to cutting operations unless grave indications due to 
pressure upon the thoracic organs should exist. 

Pathological Dislocations. To the three examples of this kind quoted 
by Malgaigne, Bourneville 2 has added a fourth. In two, as a result of 
frequent pressure against the sternum, displacement took place between 
the first two pieces, one angular with projection of the upper edge of 
the second piece, the other of the second behind the first. In the third 

1 Stetter: Compend von den Luxationen, 188(5, p. 19. 

2 Bourneville: Bull, de la Soc. Anatonrique, 1869, vol. xiv. p. ">(>. 



538 DISLOCATIONS. 

case the body of the sternum and the connected costal cartilages could 
be pressed back to a depth of two inches. In Bourneville's there was 
tubercular suppuration at the junction of the first two pieces, with 
slight displacement of the second forward. 

Dislocation of the Ensiform Process. 

Of this injury, referred to by many of the earlier writers as a pos- 
sibility, only five or six more or less well-authenticated cases are on 
record. They are those of Martin and Billard quoted by Malgaigne, 
Polaillon, 1 Gallez quoted by Servier, and Hamilton. 2 In addition may 
be mentioned the reference made by Malgaigne to an example observed 
in a new-born child by Seger, and that to one similar to Polaillon's 
quoted by Mauriceau in the discussion on his case. 

Polaillon's patient was a woman thirty-five years old, and her injury 
was caused apparently by tight lacing to conceal the enlargement of 
pregnancy; all the others were males, and their injuries were caused 
by blows received upon the epigastrium ; their ages were eighteen, 
nineteen, twenty-eight, and fifty-three years. 

No autopsy was had in any case, and in Polaillon's alone is the con- 
dition described with sufficient detail to make it reasonably certain that 
the separation took place at the line of union between the process and 
the body of the sternum ; the others may have been fractures of the 
process itself. In Polaillon's the base of the process was displaced 
backward, and the point looked directly forward. In Hamilton's, first 
seen by him twelve years after the accident, the cartilage was " bent 
at right angles with the sternum, pointing directly toward the spine." 
In the other cases the character of the displacement is not fully de- 
scribed, but apparently the apex of the process was directed backward 
in most. 

In three cases the most prominent symptom was persistent vomiting, 
which in one (Hamilton's) recurred every five or six days for two 
years and then ceased spontaneously, in another (Martin) it was relieved 
by grasping the process with the fingers and drawing it forward into 
place, and in a third (Billard), after it had lasted a month and threat- 
ened to prove fatal, it was relieved by drawing the process forward by 
means of a blunt hook introduced below it through an incision. Polail- 
lon's patient suffered sharp pain, which was excited by the pressure of 
the clothing and the ingestion of food, and was extremely severe during 
delivery ; reduction was impossible, and after a time the inconvenience 
caused by it ceased. In Gallez's case the prominence could be reduced 
and reproduced with a click by manipulation ; the patient suffered only 
local pain and was promptly cured by reduction maintained by the 
aid of a small compress fixed over the process by means of adhesive 
plaster. 

1 Polaillon : Bull, de la Soc. de Chirurgie, 1877, p. 9. 

2 Hamilton : Fractures and Dislocations, 6th ed., p. 182. The account leaves it uncer- 
tain whether this was deemed a fracture or a dislocation. 



CHAPTEKXL. 

DISLOCATIONS OF THE RIBS AND THE COSTAL CARTILAGES. 

Under this title are included dislocation of the ribs at their junction 
with the vertebra?, of the ribs from the costal cartilages, of the carti- 
lages from the sternum, and of the cartilages of some of the lower, ribs 
from one another. 

The head of each rib articulates with the bodies of one or two ver- 
tebrae by a true joint containing one or two synovial sacs and strength- 
ened by firm ligaments ; the tubercle and neck of each rib, except the 
eleventh and twelfth, are united to the transverse process of the corre- 
sponding vertebra by a synovial joint and ligaments and to the trans- 
verse process of the vertebra next above by a longer ligament. The 
union between each rib and its costal cartilage is direct, without a 
synovial sac, and is strengthened on the anterior surface by the perios- 
teum. The articulations between the costal cartilages and the sternum 
are, with the exception of the first, true synovial joints, sometimes 
double, surrounded by a capsule which is strengthened in front and 
behind to form the anterior and posterior ligaments. The seventh rib 
is the lowest that articulates with the sternum. The fifth, sixth, 
seventh, eighth, and ninth costal cartilages are united with one another 
for a short distance on their contiguous margins by true synovial joints 
formed by slight projections on their margins and surrounded by 
capsules which are strengthened by fibres derived from the anterior 
intercostal aponeuroses. 

Dislocation of the Head of the Rib. (Luxatio Costo-vertebralis.) 

The first recorded case, and that a doubtful one, was reported in 
1753 to the Academie de Chirurgie by Buttet. His patient was a 
man fifty-five years old who had been run over by a w r agon ; he was so 
fat and the swelling was so great that the outlines of the ribs could 
not be traced, and the diagnosis was based on the fact that when press- 
ure was made upon the front of the chest the sixth rib on the right side 
could be felt to move with a very distinct, audible click which, moreover, 
was reproduced whenever the patient made a movement of his trunk. 

The next case was Hankel's 1 in 1834 : a young man fell into a clay- 
pit and received an injury in the lower dorsal region ; he died on the 
fifteenth day, and the autopsy showed fractures of the eleventh dorsal 
vertebra and of the twelfth rib on each side and a dislocation of the 
eleventh left rib. 

During the next following six years six additional eases were re- 
ported, and the list has not since been added to except by Webster's 

1 Hankel: Gazette Medicale, 1S34, p. 187. 



540 DISLOCATIONS. 

case, the date of occurrence of which is not known but is probably 
earlier than that of the others, and by Quint. 1 

In all but one of the nine (Kennedy) the condition was shown by 
autopsy. The causes were extreme violence, falls or blows, and in 
one a gunshot wound. The ribs dislocated were the first, fourth, 
sixth or eighth, and tenth once each ; seventh, eleventh, and twelfth 
twice each ; in one case the right eleventh and twelfth and the left 
eleventh. In two cases the corresponding vertebra was broken, and in 
four one or more adjoining ribs were broken. With one exception the 
patients died promptly or within a few days in consequence of asso- 
ciated injuries. The exception was AVebster's ; in his the head of the 
seventh rib was found united with the front part of the vertebra, hav- 
ing been displaced, it was thought, in a fall from a horse several years 
before; the injury was thought at the time to be a fracture of a rib. 

Separation of the Ribs from the Costal Cartilages. 
(Luxatio Chondro-costalis.) 

Of this injury there are only eight, possibly nine, examples on 
record, and in only one of these was the condition demonstrated by 
autopsy. Of the latter our only knowledge is through the description 
of the specimen presented without history to the Societe Anatomique 
by Carbonell. 2 It showed a separation of the second, third, and fourth 
cartilages from the ribs, with fracture of the ossified union between 
the first rib and the sternum and of the fifth costal cartilage one centi- 
metre from its outer end ; all five ribs were also broken at their angles, 
and the right bronchus was torn away from the trachea. 

The other cases are those of Chaussier, 3 Bell, 4 Bouisson, 5 De Kimpe, 6 
Bradley, 7 Stimson, 8 and B. F. Curtis. 9 

In four of the cases the patient had been crushed between a moving 
body and a wall ; in two the cause was a blow upon the front of the 
chest ; in one the patient had long suffered with a cough and had 
thereby produced a hernia of the lung between the eighth and ninth 
ribs on the left side and another between the seventh and eighth ribs 
on the right side at the level of their junction with the cartilages, 
accompanied by a separation between the seventh rib and its cartilage 
on the right, and between the eighth and its cartilage on the left; at 
each of these points the rib was movable with crepitus. 

In Bell's case the ends of all the ribs on both sides projected dis- 
tinctly at their junction with the cartilages ; in the others the displace- 
ment of the end of the rib was in some forward, in some backward. 
In Bradley's all the ribs from the first to the sixth were depressed ; in 

1 Webster, Cooper on Dislocations and Fractures, Am. ed., 1844, p. 450 ; Boudet, Bull, 
de la Soc. Anatomique, 1839, vol. xiv. p. 104 ; Alcock, 2 cases, London Medical Gazette, 
1838-39, vol. ii. pp. 586 and 587; Kennedy, Dunne, and Finnecane, Dublin Medical Press, 
February and Marcb, 1841, abstracts in Gazette Med., 1841, p. 410: and Quint, Bull. 
Med. du Nord., June, 1888. 

2 Carbonell : Bull, de la Soc. Anatomique, 1865, p. 17. 

3 Cbaussier : Bull, de la Facuite, 1814, p. 50. 

4 Bell: Surgical Observations, 1817, p. 171. 

5 Bouisson : Gurlt, loc. cit., vol. ii. p. 251. 6 De Kimpe : Gaz. des Hop., 1852, p. 18. 

7 Bradley: Medical Eecord, August 24, 1890. 

8 Stimson : New York Medical Journal. March 1, 1890. 9 B. F. Curtis: Ibid. 



DISLOCATIONS OF RIBS AND COSTAL CARTILAGES. 541 

mine the second rib was dislocated backward from its cartilage, and 
the cartilages of the third to the sixth forward from the sternum. In 
Bouisson's and De Kimpe's the fourth and fifth ribs respectively were 
displaced forward. 

The possible ninth case is Monteggia\s/ a separation of the second 
and third costal cartilages in a very emaciated man seventy years old, 
in consequence of a violent attack of coughing. Gurlt says : "Mon- 
teggia declares expressly that it was not a fracture of the cartilage but 
a separation of the epiphysis," by which must be meant a separation 
at the costo-chondral junction. 

The injury is so closely allied to fracture of the cartilages that the 
reader is referred for other details to Chapter XVI. 

Dislocation of the Costal Cartilages from the Sternum. 
(Luxatio Chondro-sternalis.) 

Of this injury there are fourteen recorded examples : Ravaton, 
Manzotti, Monteggia, and Bell, quoted by Malgaigne ; Cooper, 2 
Flagg, 3 Wolfenstein, 4 Gross, 5 Bennett, 6 Mulvany, 7 Blodgett, two cases, 8 
Stoner, 9 and mine quoted in the preceding section. There are, in addi- 
tion, one or two cases, elsewhere referred to (see Chapter XXXIX.), 
in which separation of the first and second pieces of the sternum has 
been accompanied by complete separation of the second costal cartilage 
from the sternum on one or both sides. 

In three of the cases (Bell, Cooper, and Blodgett' s second) the cause 
appears to have been traction exerted through the pectoralis major, in 
swinging dumb-bells, kneading bread, and exercising on parallel bars ; 
and possibly the cause was the same in Blodgett's first case, in which 
a man while carrying a piano made a violent effort to prevent its fall. 
In four others the cause was a fall or compression of the chest; in the 
remainder it is unrecorded or obscure. 

The fourth cartilage was displaced singly forward in three cases, 
forward in combination with the fifth and sixth in two, and backward 
with the second and third in one ; the third singly, the fifth and sixth 
together, and the fifth, sixth, and seventh together were displaced for- 
ward in two cases, the third to the sixth forward in one, and the first 
and second were together displaced forward and outward once (Blod- 
gett's first). In two cases it is not stated which cartilage was dis- 
placed, nor in what direction. 

The only autopsy Avas in Bennett's case. The patient was a woman 
about fifty-six years old who had been run over by a cart and died a 
few days later of pleurisy and pneumonia. The third cartilage on 
the left side was displaced forward, and there was also fracture of the 

1 Gurlt: Loc. cit., vol. ii. p. 250. 2 Cooper: Loc. cit., p. 451. 

3 Flagg: Northwestern Medical and Surgical Journal, August. 1871, quoted by Ham- 
ilton. 

4 Wolfenstein : Allg. Wiener med. Ztg., 1873, No. 44, quoted by Poinsot. 

5 Gross : Surgery, 6th ed., vol. i. p. 1132. 

6 Bennett: Dublin Journal of the Medical Sciences, 1879, i. p. 111. 

7 Mulvany : Lancet. 1882, i. p. 432. 

8 Blodgett: New York Medical Journal, 1883, vol. xxxviii. p. 34. 

9 Stoner: The Physc. and Surg., October, 1SSJ> 



542 



DISLOCATIONS. 



second, third, fourth, and fifth ribs on the same side, and of the second 
to the ninth ribs on the right side. The perichondrium with the 
attached ligaments was stripped clean off. The dislocation was reduced 
by direct pressure and did not recur ; it must be remembered, however, 
in connection with this, that the corresponding rib was broken. 

In the single case of backward dislocation (Mulvany) the patient 
was a boy fifteen years old, who while steering a ship in a heavy storm 
was thrown violently across the deck by a wave and struck upon the 
back of his left shoulder against the deck-house. The second, third, 

Fig. 277. 




Dislocation forward of the third to the sixth costal cartilages from the sternum, and of the first 

rib backward. 

and fourth left cartilages were displaced backward behind the sternum, 
and the sternal end of the right clavicle was dislocated forward. 
Reduction could be effected by drawing the shoulders backward, but 
the displacement immediately recurred when the traction ceased. The 
patient was kept upon his back for eighteen days, and the deformity 
was then found to have been much diminished. In two months lie 
was again at work. 

Usually there has been sharp local pain at the moment of the acci- 
dent, subsequently excited by movements of the thorax and by local 
pressure. In one case (Mulvany) there was slight recurrent haemoptysis. 

The recognition of the injury appears always to have been easy, by 



DISLOCATIONS OF RIBS AND COSTAL CARTILAGES. 543 

attention to the difference in level between the cartilage and the 
sternum. In only one case (Wolfenstein) was it mistaken for a local 
inflammation. 

Reduction of the forward dislocations was in every case easily effected 
by direct pressure, but the tendency to recurrence was marked. 

The best treatment would appear to be the application over the dis- 
placed cartilage and around the chest of a broad strip of adhesive 
plaster, as in fracture of a rib, making special local pressure, if neces- 
sary, with a compress. Possibly a truss could be used with advantage. 

Dislocation of One Cartilage upon Another. 
(Luxatio Chondro-chondralis.) 

Malgaigne collected three supposed cases, one of which came under 
his own observation. I think they should rather be classed as dislo- 
cations of the ribs from the cartilages, or of the cartilages from the 
sternum, although there was also displacement above or below the level 
of the adjoining ribs. 

In the following two the character of the lesion is more apparent : 

Hochenzegg l presented to the Gesellschaft der Aertze in Vienna a 
patient thirty years old, who in a fall broke the bond between the 
seventh and eighth ribs. A year later after a fit of coughing he felt 
something give away in his side and found a wide space between those 
ribs. 

Aunis 2 found in a man fifty years old a dislocation forward of the 
seventh cartilage from the eighth ; it could be reduced by pressure, but 
immediately recurred. The injury was caused by a fall backward. 

1 Hochenzegg: Medical Press and Circular, Dec. 17, 1890. 

2 Aunis : Gaz. Hebdom., March 13, 1892. 



CHAPTER XLI. 

DISLOCATIONS OF THE CLAVICLE. 

Of the Sternal End : Forward, backward, upward — Of the Acromial End . 
Supra-acromial, subacromial, subcoracoid — Simultaneous of Both Ends. 

Of all dislocations about 5 per cent, are of the clavicle, those of the 
acromial are five times as frequent as those of the sternal end. The 
period of greatest frequency appears to be between the thirtieth and 
fiftieth years, and during it the injury is almost wholly confined to 
males. 

The dislocation may be of either end or of both, and occasionally 
both clavicles have been simultaneously dislocated. 



1. DISLOCATIONS OF THE STERNAL END OF THE CLAVICLE. 

Anatomy. The sternal end of the clavicle is so much larger than 
the clavicular notch of the sternum with which it articulates that it 
projects above it and in front and behind. The articular surfaces are 
separated from each other by an interposed fibro-cartilaginous disk, or 

meniscus, which is most strongly at- 
tached above to the upper edge of 
the end of the clavicle, and below 
to the cartilage of the first rib. On 
each side of it is a synovial cavity. 
The ligaments of the joint are the 
interclavicular, costo-clavicular, and 
the anterior and posterior sterno- 
clavicular. The interclavicular liga- 
ment extends across from the upper 
edge of the end of one clavicle to that 
of the other above the interclavicular 
notch of the sternum, sending bun- 
dles of fibres into the meniscus and 
to the top of the sternum. The costo- 
clavicular ligament extends from the 
sternal end of the first rib upward 
and outward to the under surface of the clavicle as far as to the sub- 
clavian vein, partly surrounding the inner end of the subclavius mus- 
cle but lying mainly behind it. It sometimes contains within itself a 
bursa of considerable size. The anterior and posterior sterno-clavicular 
ligaments cover the joint in front and behind respectively, mainly con- 
stituting its capsule. They are short and quite tense. 

544 




Frontal section through the sterno-clav- 
icular joint. J, rhomboid, or costo-clav- 
icular ligament ; B, meniscus ; C, inter- 
clavicular ligament. (Hexle.) 



DISLOCATIONS OF THE CLAVICLE. 545 

Motion is possible about all the axes to this extent, that the acromial 
end of the bone can be made to describe a circle which is the base of 
a cone having an angle of 60 degrees at its apex in the joint. Move- 
ment of the shoulder downward and backward is arrested by contact 
of the clavicle with the first rib, and if then continued this point of 
contact becomes the centre of motion, or the fulcrum, and the sternal 
end of the clavicle is forced upward or forward out of its place, and 
a dislocation is produced. 

Varieties. The dislocation may be complete or incomplete, upward, 
forward, or backward ; and when complete it is usually also inward, 
toward the median line, and when complete forward or backward it is 
usually also downward. Possibly a separate class of dislocations, 
upward and outward, should be made of such cases as those of Stokes 
(vide infra), in which the cause is the prolonged action of the sterno- 
cleido-mastoid muscle in forced inspiration. 

Dislocation Forward. (Luxatio Claviculae Prsesternalis.) 

This is the most common form, and is usually caused by the shoulder 
being forced backward, or backward and downward. The means by 
which this movement has been produced are various ; in some cases it 
has been a fall upon the point of the shoulder or upon the extended 
hand ; in others, the pressure of some heavy object upon the front of 
the shoulder when the body was supine, as the wheel of a wagon or the 
foot of a horse ; in others, again, by the sudden slipping of a heavy 
burden carried upon the back by straps passing around the shoulders. 

Richerand l reported a case in which it was caused in a girl twenty 
years old by the forcible approximation of her elbows behind her back, 
and Boyer another in which the shoulders were drawn back to give the 
patient, a young girl, a more erect and graceful carriage. In like man- 
ner, it has been caused by the voluntary throwing back of the shoulders, 
as in soldiers at drill, and in one case, Bardenheuer, 2 by the involun- 
tary effort made to prevent the fall of a burden carried upon the head. 

In all of these the mechanism is the same : the outer end of the 
clavicle is carried back to the limit of the normal range of motion, and 
then it either finds a new centre of motion at the point at which it 
comes into contact with the first rib, in consequence of which the 
inner end is carried forward if the movement is prolonged, or the ante- 
rior sterno-clavicular ligament is put upon the stretch and ruptured, 
and then dislocation takes place. 

In a few cases it has been gradually produced, apparently by relax- 
ation of the ligaments due to repeated slight strain, the dislocation then 
occurring wdienever the arm was raised and being spontaneously reduced 
when it was lowered. In one of my cases both clavicles were thus 
affected. The same condition of easy recurrence and reduction may 
follow a primary traumatic dislocation. 

In a few cases the dislocation has been caused by the pressure of an 
aneurism at the root of the neck, and in others 3 by prolonged, forced, 

1 Richerand: Quoted by Polaillon, loc. eit., p. 729. 

2 Bardenheuer: Deutsche Chirurgie, Lief. 63, a. p. 57. 

3 Stokes: Dublin Medical Journal, 1852, vol. xiii. v. 459. 
35 



546 DISLOCATIONS. 

inspiratory efforts. In the latter (two cases) the dislocations appear to 
have been primarily upward, and the displacement forward to have 
been the consequence of the elongation of the ligaments. In one of 
them both clavicles w T ere dislocated. 

Cazin 1 reported a case in which the dislocation was gradually pro- 
duced in a boy eleven years old who was suffering from Pott's disease 
of the dorsal spine with angular deformity and retraction of the corre- 
sponding side of the chest, and who had the habit of resting on his 
elbows in bed. Cazin thought the displacement was due to the dimi- 
nution of the size of the upper part of the chest, not to the force 
exerted through the arm. 

Age. According to Bardenheuer, Fergusson met with a case in which 
the dislocation was produced in a child during delivery. The next 
earliest age at w^hich the injury has been reported is ten months ; it 
was caused by a fall from bed. 2 

Pathology. The dislocation may be complete or incomplete ; in the 
latter form the posterior portion of the articular surface of the clavicle 
remains in contact with that of the sternum, and the anterior sterno- 
clavicular ligament alone is ruptured. In the former the articular 
surfaces are completely separated, and the posterior edge of that of the 
clavicle rests upon the front of the sternum ; ordinarily it lies nearer 
the median line and at a lower level than that of its normal position, the 
greatest recorded displacements being one mentioned by Richerand, 
three inches downward, and one reported by Jousset 3 in which the end 
of the clavicle lay upon the second rib. This displacement inward or 
downward or in both directions must be secondary and due to the 
action of the weight of the corresponding limb and to the contraction 
of the muscles which draw the shoulder inward, downward, and for- 
ward when it is deprived of its normal support, in the same manner 
and for the same reasons as after fracture of the clavicle. The oppor- 
tunities for post-mortem examination have been so few that a positive 
account of the condition of the ligaments cannot be given. That the 
anterior one is ruptured cannot be doubted, and it is probable that the 
posterior one also is torn, although in some cases it may only be torn 
from its attachment and left continuous with the stripped-up perios- 
teum of the posterior surface of the clavicle. In one case 4 all the liga- 
ments except the anterior sterno-clavicular are described as intact ; the 
meniscus accompanied the clavicle and w r as partly torn. In a case 
reported by Cloquet 5 there was found at the autopsy instead of rupture 
of the posterior ligament a fracture that split the end of the clavicle 
into two parts, the posterior one of which remained in place, while the 
anterior one, continuous with the shaft of the bone and capped by the 
meniscus, was dislocated forward. Whether or not the meniscus habit- 
ually accompanies the end of the clavicle in its displacement is not 
known. 

In the cases in which the dislocation has been slowly produced, 
Stokes's and probably Heusinger's, the ligaments were found greatly 

1 Cazin : Gaz. des Hopitaux, 1874, vol. xlvii. p. 507. 

2 T. E. Wright : Boston Medical and Surgical Journal, 1880, vol. cii. p. 333. 

3 Jousset : Gaz. Medicale, 1833, p. 217. 4 Bull, de la Soc. Anatomique, 1879, p. 809. 
5 Cloquet : Nouveau Journ, de Med., 1820, vol. vii. p. 248, quoted by Polaillon. 






DISLOCATIONS OF THE CLAVICLE. 547 

elongated but not torn. Stokes does not mention the position of the 
meniscus ; in Heusinger's case it accompanied the clavicle. 

Occasionally a portion of the edge of the articular surface of the ster- 
num or of the clavicle has been broken off. The sternal portion of the 
sterno-cleido-mastoid may be pushed aside or even torn away from the 
sternum, perhaps bringing with it a scale of bone. 

Simultaneous dislocation of the acromial end (vide infra) and frac- 
ture of the shaft have been observed as complications; also a similar 
dislocation of the other clavicle. 

Symptoms. The principal physical sign is the projection of the end of 
the clavicle and, if the dislocation is complete, its displacement toward 
the median line or downward. If the dislocation is incomplete the 
projection can be made to disappear by pressing it backward, but it is 
likely to reappear when the pressure is removed. In the complete dis- 
locations the weight if the limb, if unsupported, tends to bring the 
shoulder nearer the thorax and thus forces the end of the clavicle 
inward or downward. 

The other symptoms are sharp local pain, which abates in a day or 
two, depression of the shoulder, inclination of the head toward the 
injured side, and inability to raise the arm. 

The local swelling may be so great as to mask the position of the 
bone, and if crepitus should be present the injury may be, as it has 
been, mistaken for fracture. Another error of diagnosis has been 
to mistake the dislocated end for an exostosis ; and, conversely, hyper- 
trophy of the bone has been mistaken for a dislocation. 

Prognosis. The prognosis is unfavorable as regards the complete 
correction of the deformity, but favorable in respect of the restoration 
of function. In almost all the reported cases projection of the end of 
the bone, to a greater or less extent, has persisted, but the patients have 
been able to use the arm freely and with no sense of loss of power, 
even when the dislocation has remained complete. In some the con- 
dition of " habitual " or " recurrent " dislocation ensues, the bone 
slipping out of place whenever certain movements of the arm are 
made. The discomfort caused thereby may be very great. 

Treatment. Reduction is effected by drawing the shoulder outward 
and slightly backward and making pressure backward on the dislocated 
end after it has been thus brought opposite the joint. Hamilton foiled 
in two cases to effect reduction, but I have met with no other reported 
failures. The reduction is, however, the least part of the treatment ; 
the difficulty is to keep the bone in its place. The anatomical rela- 
tions and the mode of production suggest that this would best be 
effected by keeping the shoulder well forward until after repair of the 
torn ligaments shall have taken place, and I can account for the fail- 
ures under this plan, which was recommended by Yelpeau and Mal- 
gaigne, only by supposing that it was not properly carried out. I have 
found it easy to maintain the position by a figure-of-eight bandage about 
both shoulders, the turns crossing in front of the chest, and also by a 
plaster-of- Paris dressing about the shoulder and chest. In the simpler 
cases it is sufficient to immobilize the shoulder without drawing it for- 
ward, and to prevent the elevation of the arm. 



548 DISLOCATIONS. 

Moulded pads of leather, gutta-percha, or plaster of Paris covering 
the end of the bone and the adjoining part and held in place by band- 
ages about the chest have given good results. 

Direct pressure, usually in conjunction with fixation of the shoulder, 
has been applied in a great variety of ways, of which the simplest, 
which may serve also as the type, was that employed by Nelaton. He 
used an ordinary spring-truss, placing one of its pads upon the sternal 
end of the clavicle and the other between the shoulder-blades, and 
carrying the spring under the axilla of the uninjured side. The objec- 
tion to the use of pressure arises from the probability of irritating the 
skin or even causing a slough at the point at which it is applied. 
Combined with rest in bed upon the back and a good position of the 
shoulder, the maintenance of the pressure for a week has proved suffi- 
cient to prevent recurrence, although not entirely to overcome the pro- 
jection. 

In a case in which the total correction of the displacement would 
be important, the patient should be kept in bed upon the back, in order 
to diminish the tendency to reproduction of the deformity created by 
the weight of the shoulder when the body is erect, and frequent inspec- 
tion should be made to determine the efficiency of the measures. 
Should all other means fail, digital pressure might be maintained 
for a week or ten days. The dressings should be worn for at least a 
month. 

Habitual or recurrent dislocation has been successfully treated by 
prolonged retention, and in two cases by myself 1 by peri-articular injec- 
tions of alcohol ; a few drops of alcohol are injected with a hypodermic 
syringe into the tissues in front of and below the joint, and the arm 
immobilized, or, at least, elevation of the elbow is avoided. In one 
case I made four injections at intervals of about a week ; in the other 
one injection was sufficient. 

Dislocation Backward. (Luxatio Claviculse Retrosternalis.) 

This dislocation, the second in order of frequency of those of the 
sternal end, may be produced directly, by a force acting from before 
backward upon the end of the bone, or indirectly, by a force that presses 
the shoulder forward and inward. The latter is the more frequent. 
In the few recorded cases of dislocation by direct violence the cause has 
been such as a fall of the patient forward, striking upon the clavicle, 
or the fall upon him of a stone, or the passage across his chest of the 
wheel of a Avagon. In the dislocations by indirect violence the patient 
has commonly been caught between two bodies, as the pole of a wagon 
and a wall, or the side of a railway car and a wall, or between two 
boats, in such a way that the shoulder has been pressed forward and 
inward. 

The dislocation may be complete or incomplete. 

Pathology. The only recorded cases in which direct inspection of 
the parts has been made are those of Tyrrell 2 and Bennett. 3 In the 

1 Stimson : New York Medical Journal, November 23, 1889. 

2 Tyrrell : St. Thomas's Hospital Eeports, 3836, vol. i. p. 261. 

3 Bennett : Dublin Journ. Med. Sciences, 1881, vol. lxxi. p. 444. 



DISLOCATIONS OF THE CLAVICLE. 540 

former a compound dislocation was caused by the point of a pickaxe 
entering below the end of the bone ; the pectoral is major was freely torn 
from its attachment to the clavicle, but in all probability this was 
mainly, if not entirely, the result of a direct action upon it of the 
point of the pickaxe, and is not a common feature of the dislocation. 
The meniscus remained attached to the sternum, and the end of the 
clavicle could be easily felt by the finger in the wound. 

In the second case the patient was caught between a wall and a rail- 
way car and rolled along for some distance. The sternal end of the 
right clavicle, accompanied by the meniscus, was dislocated backward, 
and the cartilages of the first, second, third, and fourth ribs of the same 
side were broken. 

The end of the bone is displaced inward or inward and downward, 
and it is generally stated that it lies between the trachea and the sterno- 
hyoid and sternothyroid muscles, but, in the absence of direct proof 
of this, I am disposed to believe rather that it may lie between the 
latter muscle and the sternum, and below the former, for, it will be 
remembered, the sterno-hyoid arises in part from the posterior ligament 
of the joint and frequently from the clavicle itself, and the sternothyroid 
lies behind the other and has its origin as low even as the cartilage of 
the second rib. Possibly the difference noted in the direction of the 
displacement, inward in some, inward and downward in others, may 
depend upon varying relations between the bone and these muscles. 

Whatever the relations between these parts may be, the end of the 
bone frequently presses upon the trachea and thereby causes more or 
less dyspnoea, or upon the oesophagus and causes dysphagia. Of six- 
teen cases analyzed by Polaillon 1 dyspnoea was present in six and dys- 
phagia in three. The venous congestion of the face and neck coexisting 
with the dyspnoea has been sometimes attributed to pressure upon the 
brachio-cephalic vein, but although the region into which the end of 
the bone is displaced is occupied by most important vessels and nerves, 
the recorded histories do not show that they have ever been seriously 
pressed upon. 

Beside the complication of fracture of the cartilage of the first four 
ribs in Bennett's case mentioned above, fracture of the first rib has been 
noted in a case reported by Dr. N. C. Morse : 2 the patient was a girl 
eight years old who had been run over by a wagon and had received a 
dislocation backward of the sternal end of the left clavicle, with frac- 
ture of the first rib, and a dislocation " outward " (forward ?) of the 
sternal end of the right clavicle. Apparently the wheel had crossed 
the left clavicle and chest. There was great dyspnoea and marked 
venous congestion of the face and neck which disappeared on reduction 
of the dislocation. The child recovered. Geissler 3 reports a case in 
which the sternal ends of both clavicles were dislocated backward by a 
fall upon the back of the head and shoulders. Reduction was incomplete. 

Symptoms. The absence of the end of the clavicle from its articu- 
lation, and its position behind the sternum are recognizable by inspec- 
tion and palpation, the course of the bone can be seen and felt to pass 

1 Polaillon: Diet. Encyolope'dique des Sciences Mod., art. Clavicule. 

2 Morse: Cincinnati Medical News, 1877, vol. vi. p. 819. 
'Geissler: Zentralblatt fur Chir., 1906, p. 709. 



550 DISLOCATIONS. 

inward behind its normal position, and the cavity and border of the 
articular surface of the sternum can be traced with the finger. 

The shoulder hangs a little forward and nearer the chest ; sharp pain, 
increased by movements of the arm or head, is felt at the seat of injury, 
but usually is prompt to disappear. These voluntary movements are 
restricted or abolished by the pain. 

Disturbance of respiration by compression of the trachea has been 
noted in only about one-third of the cases, and may be slight or so 
severe as to threaten suffocation. Ordinarily it lasts for only a short 
time, even if the dislocation remains unreduced. 

Difficulty in swallowing has been less frequently noted than dysp- 
noea (three times in sixteen cases). 

Prognosis. The prognosis is favorable as regards the re-establish- 
ment of function even if the dislocation is not reduced, and reduction 
is, as a rule, easy, and retention more complete than after dislocation 
forward. 

Treatment. Reduction can commonly be effected by drawing the 
shoulder outward and backward, and this seldom requires more force 
than the surgeon himself can exert without assistance. In one case 
Lenoir was obliged to provide counter-extension by a bandage carried 
around the chest and made fast to the wall, and extension by another 
bandage passed around the upper part of the arm and drawn upon by 
two assistants while a third held the elbow near the side. In another 
of his cases one assistant placed his knee against the patient's back and 
drew his shoulder backward while a second assistant held up the chin, 
and Lenoir passed his finger down behind the end of the clavicle and 
pressed it forward. Reduction took place promptly and with a distinct 
snap. 

Recurrence of the displacement should be opposed by dressings that 
hold the shoulder back and down. The necessity exists as in disloca- 
tion forward to examine the joint frequently with the object of promptly 
detecting and correcting any faulty position, and to wear the dressings 
for several weeks. 

Dislocation Upward. (Luxatio Claviculse Suprasternalis.) 

The first recorded case of this form of dislocation was published by 
Duverney * in 1751, the next was observed by Sedillot 2 in 1835, and 
Malgaigne in 1855 could collect only five cases. The number is now 
increased to about twenty, 3 with two autopsies, Duverney's and R. W. 
Smith's. 4 It differs from the forward dislocation in that the bone lies 
behind the sternal portion of the sterno-cleido-mastoid muscle instead 
of in front of and below it. 

The cause in the sudden, traumatic cases, is the forcible depression 
of the shoulder and the acromial end of the clavicle, by which the 
upper portion of the capsule is torn and the end of the bone lifted out 
of the joint ; then, the force continuing to act and pressing the shoulder 

1 Duverney : Traite des Maladies des Os, vol. i. p. 201. 

2 Sedillot : Contributions a la Chirurgie, 1868, vol. i. p. 261. 

3 For the bibliography see Malgaigne, Hamilton, and Polaillon, and cases herp men- 
tioned passim, and Evans, Gaillard's Medical Journal, Marcb, 1888. 

4 R. W. Smith: Dublin Journal Medical Sciences, 1872, vol. ii. p. 450. 



DISLOCATfOXS OF THE CLAVICLE. 



551 



inward toward the chest, the bone is forced inward to or beyond the 
median line and sometimes upward so far even as to rest upon the ante- 
rior surface of the larynx. A unique mode of production was reported 
by Dr. A. N. Blodgett. 1 The patient was carrying one end of a piano 
when the two men who were carrying the other end allowed it to fall. 
The patient felt a sharp pain at the root of the neck and front of the 
chest, and it was found that the sternal end of the right clavicle had 
been dislocated upward and inward and that the first and second costal 
cartilages of the same side had been dislocated from the sternum for- 
ward and outward. 

In Duverney's case all the ligaments were torn and the periosteum 
was stripped from the end of the clavicle ; probably, therefore, the 
meniscus remained attached to the sternum. In R. W. Smith's case, 
the end of the left clavicle rested on the upper border of the sternum 
in contact with the right sterno-cleido-mastoid, having passed behind 
the sternal portion of the left sterno-cleido-mastoid and in front 
of the sterno-hyoids. The anterior and posterior sterno-clavicular 
ligaments and the costo-clavicular were torn ; the meniscus accom- 
panied the clavicle. The subclavius muscle was relaxed but not torn. 
There were dyspnoea and dysphagia ; death was the result of associated 
injuries. 

Fig. 279. 




Dislocation upward of the sternal end of the clavicle. (R. W. Smith.) 

In a case reported by Stokes, 2 and mentioned above, the dislocation 
is described as forward and upward, and the joints as being so loose 
that the sternal end of each clavicle could be easily moved in any 
direction ; this condition had been produced by the " powerful action 
of the sterno-cleido-mastoid muscles" in forced inspiratory efforts pro- 
voked by great dyspnoea due to ascites. At the autopsy the ligaments 
were found to be greatly stretched, the sterno-clavicular being half as 
long again as natural and the rhomboids (costo-clavicular) also elon- 



1 Blodgett : New York Medical Journal, 1883, vol. xxxviii. 
2 Stokes: Dublin Medical Journal, 185:2, vol. xiii. p. 459. 



l>. 34. 



552 DISLOCATIONS. 

gated. The relations of the end of the clavicle to the sternal portion 
of the sterno-cleido-mastoid are not stated, and it remains uncertain, 
therefore, whether the case properly belongs in the class of dislocations 
upward. 

Symptoms. If the dislocation is incomplete the only symptoms are 
the projection of the end of the clavicle above its normal position, and 
the local pain increased by movements of the head and arms. 

The symptoms of the complete form are the recognizable displace- 
ment of the end of the bone inward and upward to a variable distance, 
its position behind the sternal portion of the sterno-cleido-mastoid of 
the same side, the depression of the shoulder, and its approximation to 
the chest ; local pain, sometimes dyspnoea and dysphagia, inhibition of 
voluntary movements of the shoulder and head because of pain, and 
sometimes the impossibility of passively raising the shoulder. The 
emptiness of the clavicular notch of the sternum may, perhaps be 
recognized by palpation. 

Treatment. Eeduction is effected by drawing the shoulder outward 
and making direct pressure downward and outward upon the sternal 
end of the clavicle, but here again the chief difficulty is to prevent 
recurrence. Fixation of the shoulder by various dressings and the 
recumbent position to avoid the depression of the shoulder by the 
action of gravity have been employed with a fair measure of success, 
the resulting deformity being slight and the re-establishment of the 
usefulness of the arm complete. 

2. DISLOCATIONS OF THE ACROMIAL END OF THE CLAVICLE. 

Anatomy. The clavicle is attached to the scapula at two points, 
namely : at its extreme end to the inner margin of the acromion by the 
acromio-clavicular joint, and further inward to the coracoid process by 
the coraco-clavicular ligaments. The articular surfaces forming the 

Fig. 280. 
Trapezoid 




Ligaments uniting the clavicle to the scapula. (Henle.) 

acromio-clavicular joint are flat and oval in shape, the long axis being 
antero-posterior, and the upper edge of the end of the clavicle rises to 
a variable distance above the upper surface of the acromion. The 



DISLOCATIONS OF THE CLAVICLE. 553 

articular surfaces are separated in part, sometimes completely, by an 
interposed meniscus of fibrous tissue, wedge-shaped, with its base 
directed upward and attached to the broad, strong superior ligament ; 
the inferior ligament, usually much thinner than the superior, closes the 
joint below. The coraco-clavicular ligament is composed of two 
portions, the postero-internal, or conoid, and the antero-external, or 
trapezoid. 

Complete dislocation involves not only the rupture of the ligaments 
of the joint proper, but also of the conoid and trapezoid ligaments to 
a greater or less extent. The joint allows motion in all directions, the 
extreme ranges being, according to Albert, 20 to 30 degrees in the 
horizontal plane, and 60 to 70 degrees in the vertical plane ; and its 
dislocation appears to be commonly effected, not by extending the 
movement of the joint beyond its normal limit, but by direct displace- 
ment of one bone upon the other. 

The clavicle may be displaced upward, supra-acromial dislocation, 
or downward and backward, subacromial dislocation, or downward and 
forward under the coracoid process, subcoracoid dislocation. The first 
is by far the most common ; the last has been observed by only two 
surgeons, one of whom reported five cases. 

Some authors, following the system of nomenclature used in the dis- 
location of other joints, term them dislocations of the scapula, but the 
innovation has not made its way. 

Supra-acromial Dislocation. (Luxatio Claviculae Supra- 

acromialis.) 

The dislocation may be complete or incomplete ; in the latter the 
clavicle is displaced upward to a distance equal or nearly equal to the 
vertical diameter of its articular surface ; in the former the separation 
of the articular surface is complete, and there is an additional displace- 
ment outward over the acromion, or outward and backward, or to a 
greater distance upward. 

The cause is usually a blow received upon the point of the shoulder 
and directed downward with an inclination inward, forward, or back- 
ward. The vigorous contraction of the trapezius by which the clavicle 
is prevented from accompanying the acromion in its descent seems to 
be an important, perhaps an essential, factor in the production of the 
lesion, the alternative factor that has been suggested, arrest of the 
descent of the clavicle by contact with the first rib, seems more likely 
to produce dislocation of the sternal end of the bone. Malgaigne 
found in one case marked tenderness of the trapezius and stcrno-cleido- 
mastoid muscles, and cites the fact as proof of the correctness of this 
theory in some cases. The absence of such tenderness in other cases 
should not, I think, be deemed opposing evidence, for an efficient con- 
traction not followed by injury of the muscle is easily conceivable. A 
case reported by Cloquet, 1 and sometimes quoted as an example of dis- 
location by direct violence, seems clearly to indicate the important part 
played by muscular action : A man who was carrying a beam upon his 
1 Cloquet: Journal Hebdomadaire, 1830, vol. vii. p. 400, quoted by Malgaigne. 



554 DISLOCATIONS. 

shoulder made a violent effort to keep it from falling, and found he had 
thereby produced a dislocation. Polaillon 1 mentions a case communi- 
cated to him by Dolbeau in which the dislocation was caused in a 
woman by an attempt to strike a child. In such a case the momen- 
tum of the arm presumably takes the place of the more common exter- 
nal violence received upon the shoulder. In one of my cases the dis- 
location was caused by a blow from a falling brick, which also broke 
the acromion at its base and dislocated the humerus. (See Chapter 
XLII.) 

A unique case in which the dislocation was caused by a blow 
received upon the clavicle from below upward is reported by Hamil- 
ton ; 2 a bolt three-quarters of an inch in diameter was driven through 
the skin on the anterior margin of the left axilla, breaking the first 
rib, severing the coraco-clavicular ligaments, and forcing the clavicle 
upward from its place. 

Malgaigne reports a case in which the injury was apparently caused 
by a fall upon the elbow. 

Pathology. Our knowledge of the character and extent of the 
laceration of the ligaments is derived almost exclusively from clinical 
observation and experiments upon the cadaver, for there are only two 
autopsies and one museum specimen. One autopsy, reported by Mal- 
gaigne, 3 was in a case of incomplete dislocation and showed that the 
articular facet of the clavicle had not entirely left that of the acromion ; 
the superior acromioclavicular ligament was only stretched or perhaps 
slightly torn away from the acromion, and the inferior one was in great 
part ruptured ; on the other hand, the strong coraco-clavicular liga- 
ments were torn entirely across. There w T ere other and more serious 
associated lesions, among them a comminuted fracture of the body of 
the scapula on the same side. 

The second autopsy, made and reported by Dr. P. R. Bolton, 4 was 
in a case of my own at the Hudson Street Hospital, April, 1902. Both 
acromioclavicular ligaments were torn across, and the conoid and 
trapezoid ligaments were torn away from the coracoid process. 

The museum specimen is one preserved in St. Thomas's Hospital 
and mentioned by Sir Astley Cooper. 5 The patient was a man sixty 
years old who died of pulmonary disease seven weeks after the receipt 
of the injury. The account from which I quote states only that "the 
clavicle was found dislocated at its scapular extremity, and projected 
considerably over the spine of that bone. The acromion process, just 
where the clavicle is united with it, was broken off." Malgaigne, 
quoting apparently from some other account, says that Cooper supposed 
that all the acromial and coracoid ligaments must have been torn. He 
adds that this is what experiments upon the cadaver indicate, but that 
it is melancholy to limit one's self to conjectures when the specimen 
itself can be examined. Cooper 6 gives also a drawing of a specimen 
of an old dislocation in which the conoid ligament had become ossified. 

1 Polaillon : Diet. Encyclopedique des Sciences Medicales, art. Clavicule, p. 719. 

2 Hamilton : Fractures and Dislocations, 1880, p. 626. 

3 Malgaigne : Loc. cit., p. 432. 

4 Bolton : Annals of Surgery. October, 1902, p. 586. 

5 Cooper: Dislocations and Fractures, Am. ed., p. 313. 6 Cooper: Loc. cit., p. 312. 



DISLOCATIONS OF THE CLAVICLE. 555 

Experiments upon the cadaver have yielded results that are not 
entirely in accord with one another. Malgaigne found that even in 
incomplete dislocation the capsular ligaments were completely, and the 
coraco-clavicular partly, ruptured. Bouisson and Ader found that 
incomplete dislocation could be easily produced after division of the 
acromial ligaments and without injury to the coracoidal, and even to 
such a degree that the articular surfaces were completely separated 
vertically from each other. Ader further showed that after division 
of the coracoidal ligaments a complete dislocation could be readily 
produced and the end of the clavicle removed to a distance of two 
centimetres from the acromion. 

Instead of rupture of the upper acromial ligament avulsion of the 
edge of bone on either side to which it is attached has frequently been 
observed clinically. 

Among the recorded complications are simultaneous dislocation of 
the sternal end of the same or of the other clavicle, fracture of the 
clavicle, of a rib, of the acromion process, of the coracoid process, of 
the body of the scapula, and subcoracoid dislocation of the shoulder 
of the same side. 

Symptoms. In incomplete dislocation the deformity consists in the 
elevation of the end of the clavicle to a variable distance, not equal, 
however, to the thickness of the bone, above the level of the acro- 
mion, and this elevation can be readily recognized by palpation, and 
can generally be reduced by moderate pressure. 

In complete dislocation the elevation is greater, more than an inch 
in some cases, or is combined with displacement outward, backward, 
or forward. The displacement outward is, of course, due to the 
approximation of the acromion to the chest. The greatest recorded 
overriding is one inch (Malgaigne, Klar 1 ). It has been observed also 
in some cases that the scapula has undergone a movement of rotation 
by which its inferior angle is carried backward toward the spine, and 
the anterior, upper angle is lowered, a movement that is attributed to 
the action of the weight of the arm ; it has been observed only when 
the displacement inward of the scapula toward the chest has not been 
very marked. 

There is local pain, more or less severe, persisting for a variable 
length of time, and increased by pressure or by voluntary movements 
of the shoulder or arm. The interference with voluntary movements 
of the limb varies greatly, and corresponds measurably with the pain 
and the extent of the displacement ; some patients are completely dis- 
abled, others can use the limb quite freely. 

Diagnosis. The diagnosis is to be made by recognition of the 
changed relations of the bones, which is easy in the cases of complete 
dislocation, and seldom difficult in the incomplete. In the latter ease 
the local pain and the possibility of reducing the bony prominence by 
pressure, together with its immediate reappearance on the removal of 
the pressure, will give the clew. The question will then lie between 
dislocation and fracture of the clavicle near its end, ami this may be 
answered by tracing the outline of the acromion, comparative meas- 
urements of the two clavicles, and consideration of the presence or 
1 Klar : Deutsche. Zeitschrift fin- Chir., vol. lxxiii. p. 282. 



556 



DISLOCATIONS. 



absence of signs peculiar to fracture. The error of mistaking the 
injury for a dislocation of the shoulder appears to have been quite 
frequently made, although it is difficult to understand how it could 
occur if the examination were thorough. 

A contusion or sprain of a joint in which the end of the clavicle 
stood abnormally high might easily be mistaken for a recent disloca- 
tion, since it would present all the signs of one, but the error would 
be of slight importance and would cause no harm to the patient 
beyond perhaps a needlessly prolonged confinement of the limb. 

Prognosis. The prognosis in the incomplete form is good, for 
although the displacement has commonly persisted in some measure, 

Fig. 2S1. 





Complete supra-acromial dislocation of the clavicle. 



the resulting deformity is slight. In the complete form, with marked 
displacement, there is, in addition to the common imperfect mainten- 
ance of the reduction, an occasional inability even to make reduction. 
In such cases the functions of the limb may or may not be seriously 
interfered with by the persistence of the displacement. In the unique 
case quoted above from Hamilton, of dislocation by direct violence 
acting upon the clavicle from below upward, the bone remained dis- 
placed two inches upward, yet the patient could use the arm as freely 
and strongly as the other. On the other hand, in one of Bardenheuer's 
cases, in which the displacement persisted, the diminution of function 



DISLOCATIONS OF THE CLAVICLE. 



557 



was considerable, and the power of abduction of the arm was almost 
entirely lost. 

Treatment. In most cases the reduction of even the complete dislo- 
cation can be readily effected by drawing the shoulder either directly 
upward, or upward and outward, or backward, and at the same time 
pressing the clavicle directly toward its place. The only opposition 



Fig. 282. 










mF'" 




^^*r * 




^^^ ' r : &k 




f: , 


i 




RH BBsg'" 


___—_ -3. 


w 


P <■ 


^Hff^T.-^ 





Old dislocation of the outer end of the clavicle. 



that ordinarily needs to be overcome is the weight of the arm, which 
draws the shoulder downward and inward away from the clavicle ; with 
this is sometimes associated reflex contraction of the trapezius which 
draws the clavicle upward, and in a few cases the end of the clavicle 
has passed through the trapezius in such a way that the interposed 
fibres of the muscle have constituted a serious obstacle to reduction. 
To overcome this latter obstacle Moutet l subcutaneously divided the 
clavicular portion of the trapezius close to its insertion and was 
then able easily to restore the bone to its place and keep it there by 
a bandage. 

In making reduction the arm should be kept near the side and 
pressed directly upward. If the shoulder needs to be drawn directly 
outward, this should be done by the hand introduced into the axilla, 
or by grasping the upper part of the arm with both hands, the fingers 
resting in the axilla, and the thumbs against the projecting articular 
surface of the clavicle, and thus drawing the shoulder outward while 
1 Moutet i Montpellier Medical, 1861, vol. vi. p. 219, quoted by Polaillon. 



558 



DISLOCATIONS. 



Fig. 283. 



pressing the clavicle inward. In short, reduction is to be effected by 
forcing the acromion upward, and outward, forward, or backward, as 
may be indicated by the direction of the displacement, by pressure 
exerted upon it through the humerus, and by pressing the end of the 
clavicle in the opposite direction. 

The maintenance of the reduction was long deemed difficult. The 
weight of the arm constantly tends to reproduce the deformity, to carry 
the shoulder downward away from the clavicle, and the dressings em- 
ployed did not satisfactorily oppose it. The following simple dressing 

which I devised about 1883 
has proved perfectly satisfac- 
tory : A strip of stout adhesive 
plaster, about four feet long and 
two or three inches wide, is 
placed with its centre under the 
elbow, the forearm being flexed 
at or within a right angle, and its 
two ends are carried upward, 
one behind, the other in front, 
of the arm, and crossed over the 
shoulder at a point correspond- 
ing to the end of the clavicle, 
and then fastened to the front 
and back of the chest respec- 
tively. While applying it, the 
surgeon must press the elbow 
firmly upward and the clavicle 
downward. The eye or finger 
can readily detect through the 
plaster any recurrence of the dis- 
placement. The dressing should 
be worn for three or four weeks. 
Wiring of the clavicle to the 
acromion has been practised a 
few times in recent and in old 
dislocations, but is not generally 
approved ; if anything of the 
kind should need to be done 
periosteal catgut sutures would 
probably be sufficient. 




Dressing for supra-acromial dislocation of the 
clavicle. 



Subacromial Dislocation. (Luxatio Claviculae Subacromialis.) 

This dislocation, of which Petit was the first to make mention, is so 
rare that Polaillon, in 1875, could collect only six recorded cases; the 
list has now been increased to eleven, or, adding Xewman's, to twelve. 
The first four, quoted by Malgaigne, l are those of Melle, 1765, Fleury, 
1816, Tournel, 1837, and Baraduc, 1842. The others are two observed 

1 Malgaigne: Loc. cit., pp. 448 and 452. Malgaigne thinks Baraduc's case was prohably 
pathological, not traumatic. The reference be gives for Tournel is incorrect ; it should 
be 1837, not 1847. 



DISLOCATIONS OF THE CLAVICLE. 559 

and reported by Morel-Lavallee/ one by Dr. W. B. Chase, 2 one by 
Dr. J. X. Allen 3 and one by Dr. Eaton. 4 Konig 5 refers to one that 
was observed in Bruns's clinic, and Bardenheuer 6 makes several quo- 
tations from the report of a case by Uhde, but does not give the refer- 
ence. He speaks also of a case reported by Gosselin in 1881, but I 
have been able to find only a clinical lecture by Gosselin on a case of 
supra-acromial dislocation. To these may be added Newman's case of 
simultaneous dislocation of both ends of the clavicle {vide infra), in 
which the outer end was displaced under the acromion. 

The cause in these cases was direct violence exerted upon the upper 
surface of the outer end of the clavicle (Melle, Tournel, Chase), a fall 
upon the shoulder in three (Fleury, Morel-LavalleVs two), and mus- 
cular effort in one (Allen). 

Allen's patient, a stout muscular girl sixteen or seventeen years old, 
was chopping wood, and at the moment she had the axe raised and 
was about to deliver the blow she felt a sharp pain in the shoulder, and 
the arm fell powerless by her side. When seen six weeks later there 
was a marked depression on the top of the shoulder, much discoloration 
in the axilla, and the inferior angle of the scapula was thrown promi- 
nently outward. There was complete loss of voluntary motion of the 
arm and hand, and numbness of the entire limb. Reduction was easily 
effected by drawing the shoulder outward and backward. 

Chase's case may be taken as a type of direct violence. A boy 
eight years old fell head foremost from a height of twelve or fifteen 
feet and struck with the top of his shoulder against the rung of a 
ladder. An ecchymosis over the outer end of the clavicle showed where 
the blow had been received. The acromial end of the clavicle was dis- 
located downward and somewhat backward, the shoulder was flattened 
in front, and the acromion very prominent. Reduction, under anaes- 
thesia, was easily effected by drawing the shoulder outward and 
backward and pressing the clavicle in the opposite direction. 
There was no tendency to recurrence and recovery was complete in 
five weeks. 

Of the other two cases of direct violence, in one, Tournel's, the 
injury was caused by a horse stepping upon the front of the patient's 
shoulder as he lay on the ground ; in the other, Melle's, the patient, 
who was a Russian soldier, attributed the injury to an effort he made 
when six years old to lift, with the aid of another child, a keg of water 
by means of a stick resting on his shoulder. He had also a dislocation 
of the corresponding humerus, which apparently had been received at 
the same time. 

The autopsy in Melle's case and experiments upon the cadaver show 
that the ligaments uniting the acromion and coracoid to the clavicle are 
completely ruptured ; the clinical facts show that the displacement of 
the clavicle is not only downward and outward under the acromion but 

1 Morel-Lavallee : Bull, de la Soc. de Chir., 18(5;$, vol. iv. pp. 51 and 240, 

2 Chase : Transactions of the Medical Society of (he State of New York. 1879, p. 170. 

3 Allen: New York Medical Record, 1881, vol. xix. p. 206. 

4 Eaton: New York Medical Record, 1881, vol. xx. p. 734. 

5 Konig: Speciel. Chirurgie, 3d ed.. vol. iii. p. 16. 

6 Bardenheuer : Deutsche Chir., Lief. <>l> a, p. SO. 



560 DISLOCATIONS. 

also backward to an extent that leaves the acromial facet entirely in 
front of the clavicle. This is perhaps to be accounted for by the pres- 
ence of the head of the humerus, which opposes a displacement directly 
downward ; and the same anatomical fact may explain the coincident 
dislocation of the humerus in Melle's case. The only other compli- 
cations observed clinically are fracture of the surgical neck of the 
humerus, in one of Morel-Lavallee's cases, and simultaneous disloca- 
tion of the other end of the clavicle, in Newman's ; but in experiments 
upon the cadaver fractures of the acromion and of the clavicle have 
been met with. In Melle's case the meniscus accompanied the 
clavicle. 

Symptoms. The pain at the moment of the accident may be severe 
or slight ; voluntary movements of the arm are interfered with, and 
sometimes entirely prevented ; and in one case (Allen) there was per- 
sistent numbness and tingling in the arm and hand, indicative of press- 
ure upon the brachial plexus. The appearance of the shoulder is 
affected by the sinking of the acromion and rising of the inferior angle 
of the scapula so that it appears to be inclined forward. The shoulder 
is usually approximated to the side of the head, but may be on a lower 
level than the opposite one because of the inclination of the trunk. 
The central portion of the clavicle may be depressed below the level 
of the soft parts in front and behind ; its sternal end projects sharply 
forward, and its acromial end can be traced with the finger to the point 
where it engages under the acromion a little behind the articular facet 
on the latter. An obscure part of the description of Tournel's case, 
which Malgaigne found unintelligible, seems to mean that the end 
of the clavicle passed entirely under the acromion and projected beyond 
its outer border. 1 The outline of the acromion and its empty articular 
facet can usually be traced with the finger, although in one case the 
swelling of the soft parts was very great. 

Prognosis. The prognosis is favorable ; in Tournel's case, in which 
the reduction was not attempted, the patient had good use of the limb ; 
in Melle's a new joint had formed between the under surface of the 
acromion and the upper surface of the clavicle, but the effect upon the 
functions of the limb cannot be known, for a dislocation of the humerus 
coexisted. In all the other cases in which the record is sufficiently 
complete reduction was easily effected with or without the aid of anaes- 
thesia, and there appears to have been no tendency to recurrence except 
in one case. 

Treatment. Reduction is made by drawing the shoulder outward 
and backward, the arm being kept parallel to the trunk, and counter- 
extension being made by a bandage passed around the chest. Tonrnel 
reduced by placing his knee between the shoulders and drawing them 
forcibly backward ; and Uhde did likewise, at the same time pressing 
the clavicle forward. The arm should be fixed against the trunk, and 
the forearm supported by a body bandage and sling. 

1 The phrase is : " L'epaule presentait en outre deux saillies ; une interne et superieure 
formee par l'acromion, l'autre externe et inferieure formee par l'extremite externe de la 
clavicule." 



DISLOCATIONS OF THE CLAVICLE. 561 

Subcoracoid Dislocation. (Luxatio Claviculse Subcoracoidea.) 

Authority for the belief that this singular displacement has ever been 
clinically observed rests upon the statements of two surgeons, Godemer 
and Pinjon. Godemer met with his first casein 1833 and with four 
others in the following five years ; Pinjon reported a sixth example in 
1842. Godemer's cases were reported to the Societe medicale d' Indre 
et Loire, and published in 1843 ; his paper was republished by Mal- 
gaigne in the Revue medico-chirurgicale de Paris, 1847, vol. ii. p. 155 ; 
Pinjon's case was reported in the Journal de Medecine de Lyon, 1842, 
vol. iii. p. 58. All systematic writers upon the subject are agreed in 
viewing these reports with much suspicion because of their remarkable 
similarity in detail and the great anatomical obstacles to the production 
and maintenance of the displacement. 

The features, as described by Malgaigne, are as follows : Four of the 
six patients were between the ages of sixty-seven and seventy-one 
years ; the remaining two are described as adults. In every case the 
injury was caused by a fall upon the shoulder. 

The symptoms were : 1st. More or less pain and a large ecchymosis 
in the coraco-acromial region. 

2d. A depression at the normal position of the clavicle ; this bone 
was found to be inclined downward and outward, and its acromial end 
lodged in the axilla. 

3d. The coracoid and acromion processes were prominent under the 
skin. 

4th. The shoulder was inclined downward and forward ; the inferior 
angle and posterior border of the scapula formed posteriorly a projection 
which disappeared when the shoulder was carried upward and backward. 

5th. The arm was dependent, but could be easily moved in any 
direction except upward and inward. 

Godemer made reduction in three cases by grasping the clavicle and 
disengaging it from under the coracoid process, while an assistant 
forced the shoulder backward and outward. In his other two cases 
the swelling prevented reduction before the third day. Pinjon failed 
to reduce because of the fainting of his assistant ; the next day reduc- 
tion was made by a " bone-setter/' 

3. SIMULTANEOUS DISLOCATION OF BOTH ENDS OF THE CLAV- 
ICLE. (TOTAL DISLOCATION.) 

The recorded cases of this injury are now eleven in number : Riche- 
rand, 1 Morel-Lavallee, 2 North, 3 Hutchinson, 4 Haynes, 5 Col, 6 Lund, 7 
Kombeau, 8 Hulke, <J Newman, 10 and Cousins. 11 Eight of the patients 

1 Kicherand : Arch. gen. de Med., 1831, vol. xxv. p. 108 ; reported by Porral, bis interne. 

2 Morel-Lavallee : Bull, de la Soc. de Cbir., 1859, vol. ix. p. 361. 

3 North : New York Medical Record, 1866, vol. i. p. 79. 

4 Hutchinson : Lancet, 1871, vol. ii. p. 711. 

5 Haynes: British Medical Journal, 1872, vol. i. p. 99. 

6 Col : Gaz. des Hopitaux, 1872, p. 893. 

7 Lund : British Medical Journal. 1874, vol. i. p. 106. 

8 Rom beau : Bull. Gen. de Therapeutique, 1S74, vol. lxxxvi. p. 537, reported h\ Gros. 

9 Hulke : Lancet, 1855, vol. ii. p. 245. 10 Newman : Ibid..' p. 524. 
11 Cousins: Journ. Am. Med. Assoc, L906, p. 19. 

36 



562 DISLOCATIOSS. 

were males, three females ; their ages ranged between thirteen and 
forty years. 

Haynes's patient, a weakly girl, thirteen years old, produced the 
dislocation while washing the back of her neck with the hand of the 
aifected side ; there was a complete dislocation forward of the sternal 
end, and an incomplete dislocation upward of the acromial end of the 
clavicle. 

In all the other cases the cause was external violence, usually very 
great. The mode of production is varied, the most common form 
appearing to be force exerted along the transverse axis of the shoul- 
ders, and pressing forward the one that suffers the injury. 

The sternal end has always been displaced forward, and the only 
additional change in position that is mentioned is, in Morel-Lavallee's 
case, that it had moved rather upward than downward. The acromial 
end was displaced backward in four cases (once to a distance of three 
finger-breadths), upward and outward twice, and once each forward 
and outward, downward, and incompletely upward. In Hutchinson's 
case the displacement is not described further than by saying that 
"when pressure was made on either end of the dislocated bone the 
other extremity rose perceptibly and protruded the skin." 

In seven of the cases reduction of both dislocations was effected and 
maintained, and the patients recovered with good use of the limb and 
but little deformity ; in some of them mention is made of more or less 
persistent projection of the sternal end. Morel-Lavallee was unable 
to reduce the dislocation of the outer end, although he made direct 
traction upon it with a hook introduced through the skin. Lund, with 
the aid of chloroform, could only bring the bone " into fair position ;" 
at the end of ten days the ends w T ere found " fixed in their new posi- 
tion." In Newman's case, dislocation of the outer end under the 
acromion, reduction was impossible ; the patient withdrew from the 
hospital on the tenth day, and remained disabled. The result in 
Hutchinson's case is not recorded. 

Treatment. Reduction has usually been effected by drawing the 
shoulder outward and backward, arid recurrence prevented by immo- 
bilizing it in a suitable position by means similar to those employed 
when the dislocation involves either end alone. Hulke used a gutta- 
percha splint moulded over the clavicle and bound down by a bandage 
that crossed the shoulders and was made fast in front and behind to 
another about the waist. Cousins kept each end in place by a sand- 
bag, the patient being recumbent. 



CHAPTEK XLII. 



DISLOCATIONS OF THE SHOULDER. 



Fig. 284. 



Anatomy — Statistics — Classification — Anterior Dislocations : Subcoracoid 5 in« 

tracoracoid, treatment. 

Anatomy. 

The bony surfaces which enter directly into the composition of the 
shoulder-joint are the glenoid cavity of the scapula and the postero- 
internal half of the globular head of the humerus. The former is of 
irregularly oval shape, the more pointed end above and the broader 
one below, and is slightly concave, being deepened by a low fibrocar- 
tilaginous rim, which is continuous throughout with the capsule, and 
above also with the tendon of the long head of the biceps. The cavity 
looks outward and forward in a direction nearly midway between the 
sagittal and frontal planes of the body when the scapula occupies its 
usual position. 

Against this shallow surface the head of the humerus rests, being 
held in place by atmospheric pressure, the tonicity of the muscles, and 
the tension of thickened portions of the 
capsule in different positions of the limb. 
On the outer and anterior portion of the 
upper end of the humerus is the greater 
tuberosity, bounded internally in front by 
the bicipital groove which lodges the long 
tendon of the biceps and has upon its inner 
side the lesser tuberosity. Between the 
upper margins of these tuberosities and the 
globular articular head is a shallow groove, 
the anatomical neck. 

The acromion and coracoid processes lie 
above, the one on the outer, the other on 
the inner side, and the strong coraco-acro- 
mial ligament uniting them closes in the 
upper part of the joint, but is separated 
from its cavity, as are also the two pro- 
cesses, by the interposed capsule and the 
tendon of the supraspinatus. 

The surface of the head of the humerus 
that is covered by articular cartilage is 
about one-third of that of a sphere, and the 
axis passing through its centre meets the long axis of tlu 



Acr. 




s * 

To show the relations of the hu- 
merus and scapula. \. the lesser 
tuberosity. F and S indicate the 
frontal and sagittal planes. 



jhaft at an 

angle of about 130 degrees. The linear extent of the glenoid fossa, 

563 



564 DISLOCATIONS. 

including its fibrocartilaginous rim, on a horizontal section is less than 
half as great as that of the head of the humerus ; on a vertical section 
it is about two-thirds as great. The head of the humerus, therefore, 
simply rests against the fossa, and its displacement is but slightly 
opposed by the conditions of contact between them. The muscles 
which are most closely associated with the joint are the supraspinatus, 
infraspinatus, and teres minor, attached to the greater tuberosity in 
the order named from above downward, and the subscapulars, which, 
arising from almost the whole of the costal surface of the scapula, 
passes forward, broadly covering the inner side of the joint with its 
fibres and tendon, to be attached to the lesser tuberosity. The tendon 
of the long head of the biceps, starting from the upper margin of the 
glenoid cavity, passes upward and forward over the head of the 
humerus and then down the bicipital groove, carrying with it a pro- 
longation of the synovial membrane of the joint. The deltoid, from 
its broad origin on the spine of the scapula, the acromion, and the 
clavicle, covers the joint superficially on its posterior, external, and 
anterior aspects; and the coraco-brachialis, the short head of the 
biceps, and the great vessels and nerves lie upon its inner side. 

Fig. 285. 





Horizontal section through the shoulder-joint : A, in inward, B, in outward rotation. (Henle.) 

The capsule extends from the free margin of the fibro-cartilaginous 
rim of the glenoid fossa, or from the surface of bone immediately out- 
side of it, to the anatomical neck of the humerus. At the upper part 
its scapular insertion is at the base of the coracoid process and sepa- 
rated from the glenoid fossa by the tendon of the biceps ; on the pos- 
terior and inner portion of the humerus it extends somewhat beyond 
the cartilaginous surface along the projection upon which the head rests. 
Between the two tuberosities the synovial membrane by which it is 
lined is prolonged down the bicipital groove, and is reflected over the 
long tendon of the biceps. The capsule is reinforced at some points 
by thickenings of itself which are known as ligaments and by tendons 
of the scapular muscles ; on the inner side it is perforated by the tendon 
of the subscapulars, and there shows a gap through which the cavity 
of the joint communicates with the subscapular bursa, a large pouch 
lying against the inner side of the neck of the scapula and the root of 
the coracoid process, between them and the upper part of the subscap- 
ularis. This opening lies just in front of the upper part of the ante- 
rior (inner) margin of the glenoid fossa, has the form of a slit or 



DISLOCATIONS OF THE SHOULDER. 



565 



crescent, and is" usually large enough to admit the end of the finger. 
When the synovial membrane has been dissected away the gap has the 
form shown in Figs. 286 and 287, and is partly occupied by the tendon 
of the subscapulars. The portion of the capsule which forms its 



Fig. 286. 



Supragleno-sup rahumeral 
ligament 



Sub scapular is 




The shu alder-joint from in front. (Farabeuf.) 



upper margin is called the gleno-humeral ligament, or, to adopt the 
subdivisions described by Farabeuf, 1 the supragleno-suprahumeral, the 
portion forming the lower margin is the supragleno-prsehumeral, and 



Fig. 287. 




The interior of the shoulder-joint from behind: 1, coraoo-humeral ligament; 2. supragleno- 
suprahumeral ligament; 3 supragleno-prsehumeral ligament; 4, prsegleno-subhumeral liga- 
ment ; 5, upper edge of the tendon of the subscapularis : 5', its lower part; B, biceps tendon ; 
C, coracoid; E, spine of scapula ; G, glenoid fossa. (Farabrif.) 

the portion immediately below the latter is the prsegleno-subhumeral. 
These different portions are shown in Figs. 286 ami '2S7, which are 
copied from Farabeuf s paper. Of them the one that forms the lower 

1 Farabeuf: Bull, de hi Sue. de Chirurgie, L885, p. 391. 



566 DISLOCATIONS. 

margin of the gap, the supragleno-praehumeral, is often of slight 
strength and underlies and is intimately adherent to the tendon of the 
subscapularis. 

The coraeo-humeral ligament is a strong wide band extending from 
the root and outer border of the coracoid process over the top of the joint 
to the neck of the humerus above the greater tuberosity, and is inti- 
mately connected with the capsule and the tendon of the supraspinatus. 
It is thought to play an important part in determining the position 
taken by the limb when dislocated, and the manoeuvres by which the 
dislocation can be reduced. 

The tendon of the supraspinatus passes between the acromion and 
the head of the humerus and is attached to the upper part of the 
greater tuberosity ; it is blended with the capsule and is separated from 
the acromion by a bursa. Below it come the tendons of the infraspi- 
natus and teres minor, passing to the lower and middle facets respec- 
tively and also blended with the capsule. 

Outside the capsule is a loose layer of connective tissue which sepa- 
rates it and the tendons of the outer muscles from the inner surface of 
the deltoid ; within this layer is the subdeltoid bursa, extending under 
the acromion, which deserves special mention because of the fact that 
when the tendon of the supraspinatus is torn away from its attach- 
ment in a dislocation and retracts under the acromion with the adherent 
capsule, this bursa is thereby opened and placed in communication with 
the cavity of the joint, and the upper portion of the capsule is thus 
greatly lengthened. The influence of these new conditions in favoring 
recurrence of dislocation has been discussed in Chapter XXIX. 

"With respect to the nerves and arteries it is necessary to speak only 
of the circumflex nerve and of the arterial branches which pass out- 
ward, the two circumflex and the subscapular. The circumflex nerve 
winds around behind the neck of the humerus to its outer side, to be 
distributed to the deltoid muscle and to the integument covering it. 
It may be so injured in a dislocation that the deltoid will be paralyzed, 
perhaps permanently. 

The circumflex and subscapular arteries pass outward to be distrib- 
uted among the muscles of the scapula and upper part of the arm ; 
when in a dislocation the head of the humerus presses the axillary 
artery inward, those branches are put upon the stretch because they are 
prevented by the attachment of their branches to the tissues from 
moving inward as freely as the main trunk does, and consequently they 
may be ruptured or torn away from the side of the main artery. This 
accident may be the consequence of the dislocation itself, or of the 
efforts to reduce it. 

The movements which are most frequently concerned in the produc- 
tion of a dislocation are outward rotation and abduction. In the latter 
the elbow is raised directly outward and forward from the side of the 
body by the action of the deltoid, the plane in which it moves being 
more or less exactly that which would f)e represented by the prolonga- 
tion of the broad surface of the shoulder-blade. As the movement is 
made, the head slides dowmvard on the glenoid fossa, the long head of 
the triceps, the lower part of the subscapularis, and the lower and inner 



DISLOCATIONS OF THE SHOULDER. 567 

portion of the capsule are made tense, and the movement is arrested 
when the top of the greater tuberosity comes into contact with the 
upper margin of the glenoid fossa, and the side of the shaft close below 
the tuberosity touches the acromion. If the movement is now con- 
tinued, and the arm raised to the side of the head, it is effected by the 
rotation of the scapula and the elevation of its outer portion. If, on 
the other hand, the movement is continued while the scapula is kept 
stationary, the centre of motion is transferred to the point of contact 
between the humerus and the edge of the acromion, and the head of 
the bone is forced downward against the already tense capsule and 
ruptures it at its lower and inner portion, where it presses directly 
against it. 

In outward rotation when the arm is hanging by the side or is but 
slightly abducted the movement is arrested by the tension of the cap- 
sule on the inner side, and at the same time the lower and outer part 
of the greater tuberosity comes into contact with the outer lip of the 
glenoid fossa ; if the movement is then continued the capsule yields, 
but the head does not become dislocated unless some other force 
intervenes to press it inward through the rent that has thus been 
made. 

In all the other movements similar conditions are found, and dislo- 
cations following them are less frequent only because the movements 
are themselves less frequently carried beyond the limits set by the 
structure of the joint. Thus, adduction and rotation inward are 
checked by contact of the arm with the body before the capsule is put 
upon the stretch, and extension of the arm behind the axillary line 
must be carried very far before a new fulcrum is found, and is also a 
movement that is rarely produced or exaggerated by external violence. 

Statistics. 

The great frequency of dislocation of the shoulder is fully explained 
by the structure of the joint and by its exposure to the dislocating 
action of direct and indirect violence. This frequency is so great 
that dislocations of the shoulder are about as numerous as all the other 
dislocations of the body combined. The tables of statistics given in 
Chapter XXVII. show percentages varying from 40 to 51 of all 
dislocations. Malgaigne's statistics of 489 cases contain 321 of the 
humerus, more than 65 per cent. ; Gurlt's collection of 907 cases in 
the hospitals of Berlin, Paris, and Philadelphia contain 563 of the 
shoulder, 58 percent.; Bardenheuer 1 saw 20 in a total of 37 cases 
treated in one year, 54 per cent. Kronlein's statistics, which are espe- 
cially valuable because they are made up from both hospital and poly- 
clinic records, give a total of 207 dislocations of the shoulder out of 400, 
51 per cent., of which 184 were in males and only 23 in females ; of Mal- 
gaigne's 370 cases 97 were in women ; classified according to age ami sex 
they both show that the injury is rare in youth, infrequent in old age, 
and most frequent in middle life. The youngest recorded case, excluding 
obstetrical cases, is Villar's, 2 fifteen days old. The relative frequency at 

1 Bardenheur: Deutsche Chirurgie, Lief. 63 a, p. 279, 

2 Villar: Provincial Medical Journal, August 26. 1SU2 



568 DISLOCATIONS. 

the different ages, established by taking into account the percentages 
of total population belonging to those ages, differs somewhat from the 
actual frequency, the maximum being found above the age of fifty 
years. The proportions calculated from Kronlein's statistics with the 
aid of the relative numbers of the population at the different ages, as 
given in Chapter XXVII., are five, nine, eleven, and twelve respec- 
tively for the decades from thirty-one to seventy. This relatively 
greater frequency in advanced years is much more marked in women 
than in men, a fact which is to be explained by the greater exposure 
to violence incident to the occupations and habits of men in middle 
life. It indicates, I think, that a much larger proportion of the dislo- 
cations in advanced life are due to falls while walking than in middle 
life, since that is an accident to which both sexes are more equally 
exposed than they are to others. 

The relations pointed out by Kronlein as existing between disloca- 
tions of the shoulder and those of the elbow and fractures of the 
clavicle are interesting. His statistics show that during the first two 
decades of life, a period in which dislocations of the shoulder are rare, 
dislocations of the elbow and fractures of the clavicle are most fre- 
quent. Thus, of 109 dislocations of the elbow contained in his table, 
80 of the patients were under twenty years of age, and of 100 cases of 
fractures of the clavicle collected by him 70 of the patients were under 
ten years of age ; while of 207 dislocations of the shoulder none of the 
patients was less than ten, and only 2 less than twenty years old. He 
thinks fractures of the clavicle are in childhood the equivalent injury 
of dislocations of the shoulder by direct violence in middle life, and 
dislocations of the elbow the equivalent injury of dislocations of the 
shoulder by indirect violence. 

Classification. 

The head of the humerus in leaving the joint may pass at first up- 
ward or downward, backward or forward, and may come to rest in 
any one of a great number of positions. The classification of the 
varieties is beset with much difficulty, because of their number, 
because of the frequency and importance of the secondary displace- 
ments, and last, though not least, because of the number of classifica- 
tions that have already been made and are more or less current. The 
confusion has been further increased by the application of the same or 
very similar terms to different varieties by different authors. With 
the rare dislocations backward, and the still rarer ones upward, there 
is no difficulty ; the uncertainty arises in connection with those in which 
the head of the humerus has passed across the anterior lip of the gle- 
noid fossa. A brief account of some of the classifications and terms 
heretofore and still in use will show their differences and resemblances, 
and may serve as a convenient introduction and preparation for the 
classification that must follow. 

Sir Astley Cooper's classification, upon which those now in use in 
England and America have been in the main constructed, recognized 
four kinds of dislocations : 1. Downward and inward into the axilla; 



DISLOCATIONS OF THE SHOULDER. 569 

2. Forward, the head of the humerus lying under the clavicle on the 
sternal side of the coracoid process ; 3. Backward ; 4. Partial inward, 
the head resting against the outer side of the coracoid process. It is 
apparent, from his description, that the first and fourth included the 
common, frequent cases, those which are now generally termed " sub- 
glenoid," or " into the axilla," and " subcoracoid," respectively. 

A few years later Malgaigne followed, also with four principal forms, 
but only one of them the same as Cooper's. His grouping is as follows : 



1. Subcoracoid, complete ; quite common. 
Dislocations into the axilla \ 2. Subcoracoid, incomplete ; rare. 

Subglenoid ; rare. 



(-1. g 

2. g 

1.3. S 

t.. . , (4. Intracoracoid ; most common of all. 

Dislocations inward . . •{ 5 . Subclavicular ; rare. 

t.. , , , , [6. Subacromial ; rare. 

Dislocations backward . . j ? Subspinous ; very rare. 

Dislocations upward ... 8. Supracoracoid ; only two cases known. 

All these titles are now in general use ; but while the last four, and 
perhaps the second also, are still used to designate the forms which he 
designated by them, the others have been used with different, some- 
times with widely different, meanings. The first form, the complete 
subcoracoid, was " characterized by the projection of the head of the 
humerus in the axilla, and its position exactly below the coracoid pro- 
cess ;" it would be included in Cooper's first group, dislocation down- 
ward into the axilla. His second subdivision, incomplete subcoracoid, 
was the same as Cooper's fourth, partial dislocation inward. His 
third, subglenoid, was one concerning which he seems to have been far 
from having very precise notions ; he had seen only one case, and had 
been able to collect only eleven others, and of these the symptoms 
differed widely, the head of the humerus being described as raising the 
anterior wall of the axilla in one case and the posterior in another, as 
resting against the second intercostal space in one and against the third 
in another, and even as having perforated the wall of the chest and 
lodged within it. The one feature which they had in common, and 
which he gives as pathognomonic, was that the head of the humerus 
was not immediately below and in contact with the beak of the coracoid 
process, but was separated from it by a greater or less interval. Appar- 
ently the class was created simply to collect together the odds and ends, 
the irregular cases that were not subcoracoid ; and the idea which sug- 
gested the name given to it was that the primary displacement took 
place more directly downward than in the preceding varieties. It will 
be seen that the name has since been applied to a very much larger 
proportion of cases. 

His second main division embraced two varieties, the intracoracoid 
and the subclavicular. Concerning the latter there is no misconcep- 
tion ; the term has remained in use, and with the same meaning. The 
group is made up of those cases in which the head of the humerus has 
passed entirely to the inner side of the coracoid process, and lies below 
the clavicle. But the other term, intracoracoid, is generally employed 
in a much more restricted sense than by Malgaigne. By it he desig- 



570 DISLOCATIONS. 

Rated the greatest number of dislocations, more than two-thirds of 
those he saw at the Hopital St. Louis ; he applied it to those in which 
the head of the humerus, while still remaining under the coracoid pro- 
cess, overlapped it on the inner side by more than half its own diam- 
eter. Most of such cases are now termed subcoracoid, and only those 
in which the head has passed almost, if not entirely, to the inner side 
of the process are called intracoracoid. 

The tendency of the more recent French and German writers is to 
make a single group of all the dislocations in which the humerus passes 
to the anterior side of the scapula, containing four or more subdivisions 
or varieties, two of which, the subclavicular and intracoracoid, in the 
narrower sense, are accepted by all. Of the remaining two principal 
ones, the subcoracoid and the subglenoid, the former is made to include 
the great majority, and the subglenoid is either closely and distinctly 
restricted to the very rare cases in which the head of the humerus is 
displaced directly downward upon the tendon of the long head of the 
triceps, or Malgaigne's grouping is accepted with all its diversities and 
vagueness. In the former case the group is removed from the prin- 
cipal division of " anterior " or " prseglenoidal " dislocations, and 
made to form by itself another principal division, termed " disloca- 
tions downward." 

The English and American writers, as a rule, divide the same 
cases into subglenoid and subcoracoid, basing the distinction between 
them upon the clinical feature of the greater or less facility with 
which the head of the humerus can be felt in the axilla; those in which 
it is more prominent in the axilla are " subglenoid," those in which 
it is more prominent behind the anterior wall of the axilla, close 
beneath the coracoid process, are " subcoracoid." The objections to 
this grouping are that it does not sufficiently distinguish between pri- 
mary and secondary displacements, and that the clinical features upon 
which it rests present a complete series of intermediate forms, most of 
which might be as properly placed in one group as in the other. The 
arbitrariness and uncertainty of the decision are well shown by a com- 
parison of clinical and pathological statistics. Thus, Hamilton and 
Bryant say that the subglenoid is of more frequent occurrence than the 
subcoracoid, and Erichsen says that this is the opinion of most English 
surgeons ; while, on the other hand, Flower, 1 who made an examina- 
tion of all the specimens contained in the London museums, 41 in 
number, found that in 32 the dislocation was subcoracoid, and he adds, 
that of 50 cases recently observed by him in living patients the same 
was true of " a large majority ;" 2 he calls attention to the fact that 
" the great frequency of subcoracoid dislocation observed in this series 
[of specimens] does not accord with the descriptions of this injury gen- 
erally given in the standard surgical works of the country." A few 
years later, in the article on the Injuries of the L T pper Extremity which 
he prepared in connection with Mr. Hulke for Holmes's System of 
Surgery, Mr. Flower made a classification in which the influence of 
this important investigation is apparent. It is as follows : 

1 Flower: Transactions London Pathological Society. 1861, vol. xii. p. 179. 

2 The nuinher is given as 44 in his article on Injuries of the Upper Extremity in 
Holmes's System of Surgery. 



DISLOCATIONS OF THE SHOULDER. 571 

1. Subcoracoid. Forward and slightly downward. On to the 
neck of the scapula, in front of the glenoid fossa, and immediately 
below the coracoid process. Common. 

2. Subglenoid. Downward and forward. Head of the humerus 
in front of the inferior costa [border] of the scapula, below the glenoid 
fossa. Rare. 

His remaining three divisions are Subclavicular, Supracoracoid, and 
Subspinous, the latter including Malgaigne's sixth and seventh. 

Turning now to the pathological data, to the recorded results of 
post-mortem examinations and experiments upon the cadaver, and con- 
fining our attention for the moment to the forms mainly in dispute, 
the dislocations forward (or inward) and downward, and to the points 
that affect the position of the head of the humerus, the following facts 
appear : 

The head of the humerus, when it passes across the anterior edge of 
the glenoid cavity, must, as a glance at Fig. 284 shows, move somewhat 
downward so as to get below the beak of the coracoid process ; the posi- 



Tendon 
of triceps 

To show the range of positions that may be taken by the head of the humerus after primary dis- 
placement forward or downward in any of the directions between the arrows. 

tion of the limb that most favors the production of dislocation is 
abduction with or without external rotation. The inner and lower 
portion of the capsule, being pressed upon by the head of the humerus, 
tears between the tendon of the subscapulars and the triceps, the rent 
being small or large and varying greatly in extent and direction in the 
different cases, but it is always on the anterior and inner side, and the 
head passes more or less completely through it. If the movement is 
more directly forward and inward and to a less degree downward, as 
in dislocations by direct violence received on the outer side of the 
shoulder, the head of the bone pushes the subscapulars muscle before 
it and lodges close under the coracoid process and between that muscle 
and the edge of the glenoid cavity. In this case no secondary dis- 
placement ensues, and the form would be classed as mbeoracoid by all. 
If the movement is forcible and prolonged the subscapulars may be 



572 DISLOCATIONS. 

torn entirely across and the bead may pass through it and come to rest 
on the side of the thorax under the clavicle ; or, as in a case quoted by 
Malgaigne, it may pass over the upper border of the subscapulars and 
come to rest at the same point. If, on the other hand, the primary 
movement downward has been more marked, as in dislocations effected 
by hyper-abduction of the arm, the head either passes below the sub- 
scapularis or tears its lower portion, and then, as the elbow is lowered 
the head rises, pressing the subscapularis or its untorn portion upward 
and remaining separated by it from the coracoid process. The extent 
and direction of this movement of the head are determined largely by 
the resistance of the untorn portions of the capsule, notably the outer 
and anterior part, which, by preventing the further descent of that 
part of the humerus to which they are attached, compel the head to 
move upward as the elbow descends. Other factors are found in the 
muscles ; if the head lies under an untorn subscapularis its distance 
below the coracoid process will be greater than when it lies under only 
the upper portion of the muscle, and if in addition it has passed under 
the teres major or downward as far as the lower border of the pectora- 
lis major the arm will remain widely abducted or even with the elbow 
above the head (luxatio erecta). Or, departing still further from 
what is usual, it may perhaps even turn backward after it has left its 
socket and pass under the long head of the triceps to lodge behind the 
glenoid cavity, the alleged subtricipital dislocation. 

The head of the humerus rests against the inner side of the head or 
neck of the scapula at any point between its junction with the broad 
axillary border, or inferior costa, and the middle of the anterior lip 
of the glenoid fossa, and it may lie either directly against the edge of 
this lip or further back on the side, as is clearly shown by the speci- 
mens of old, unreduced dislocations preserved in the museums. And 
according as it occupies one or the other position it will be more or 
less prominent in the axilla or more or less clearly seen and felt behind 
the pectoralis major beneath the coracoid process. 

It is evident, then, that the position in which the head of the bone 
is found bears only a limited relation to the point at which it left the 
joint, and that a classification which is sharply made upon this posi- 
tion is not only arbitrary and uncertain for a large number of cases, 
but also favors inattention to points that have an important bearing 
upon a safe and easy reduction. 

It is desirable that a classification should not deal minutely with 
unimportant variations, and that instead of multiplying divisions it 
should rather gather into a few groups those varieties that have char- 
acteristic and important features in common ; and yet, as some forms 
differ widely in their symptoms from others with which they are on 
other grounds closely related, it is equally desirable to recognize and 
note such differences. The distinction between " regular " and " irreg- 
ular " dislocations made by Bigelow at the hip can also be made at 
the shoulder, taking for the dislocations downward and forward the 
integrity or the rupture of the antero-external portions of the capsule 
as the determining feature. The following classification is, in the 
main, the same as that of Mr. Flower, above given, and the later 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 573 

French and German writers. It differs from that of the majority of 
the English and American writers in restricting the group of the 
" subglenoid " and correspondingly enlarging that of the " subcoracoid " 
dislocations. 

{Subcoracoid ; very common. 
Intracoracoid ; exceptional, 
subclavicular. 
{Subglenoid ; uncommon, 
erecta ; very rare, 
subtricipital (?) 

t> , • f Subacromial ; rare. 

Posterior < o , • ' 

(. Subspinous ; very rare. 

Upward Supraglenoid ; very rare. 

The names of the four principal divisions indicate the direction of 
the primary displacement ; those of the subdivisions the position in 
which the head of the bone lodges, with the exception of the erecta, 
which takes its name from the attitude of the limb, and the subtricip- 
ital, which rather indicates the route traversed by the head than the 
position finally taken by it. Between the anterior and the downward 
the divison cannot be sharply made, and in many of the cases included 
among the first the primary displacement has more of the downward 
than of the anterior feature, but it is believed that by enlarging the 
subcoracoid class so that it will include all but the lowest of the lower 
forms, by extending its range so that it will distinctly include the 
lower as Avell as the higher primary displacements, the necessity of 
abducting the arm to effect reduction in those cases in which the sec- 
ondary displacement upward is marked and might otherwise lead into 
error will be less liable to be overlooked. The difficulty of distin- 
guishing between the subglenoid and the lowest of the subcoracoid 
will arise in only a very limited number of cases and will be without 
practical importance; at the most it will be merely a question of 
nomenclature. 

There would be some advantage in further dividing the subcoracoid 
group into high and low. 

ANTERIOR (AND DOWNWARD) DISLOCATIONS. 

1. Subcoracoid. 

2. Intracoracoid, subclavicular. 

In these dislocations the head of the humerus passes across the 
anterior lip of the glenoid fossa, taking at first a direction that is for- 
ward and inward and more or less downward ; it may subsequently 
move upward or further inward. The class includes two subdivisions, 
the subcoracoid and the intracoracoid, of which the latter is here made 
to include also the more marked dislocation inward known as the sub- 
claviadar. 

The class embraces the subcoracoid, partial and complete, of all 
authors, most of the subglenoid of most English and American 
authors, and the intracoracoid and subclavicular of all. The tonus 
"axillary dislocations" and "dislocations into the axilla" arc nnnlieJ 



574 DISLOCATIONS. 

by some to cases that are here called subcoracoid, and the term " pec- 
toral " to the intracoracoid. 

1. Subcoracoid Dislocations. 

In this form, which includes a large majority of all cases, the head 
of the humerus lies under and in close proximity to the beak of the 
coracoid process, or at a distance below it that may equal or even 
exceed a finger-breadth. The centre of the head may be either directly 
below the beak of the coracoid process or on its outer or inner side. 
If more than three-fourths of the transverse diameter has passed to 
the inner side of the coracoid the dislocation is termed intracoracoid. 
The class, therefore, is continuous with the subglenoid below and with 
the intracoracoid on the inner side, and the separation from them is 
arbitrary and artificial, but is justified by custom and convenience in 
description. 

Malgaigne showed, as early as 1835, that in some cases the articular 
surface of the head of the humerus rested on the anterior edge of the 
glenoid fossa, and such he termed " incomplete." From time to time 
cases have been reported and the effort renewed to establish the classifi- 
cation. 1 I have seen two such cases. The formation of a separate class 
composed of such cases seems unnecessary and even undesirable, for they 
differ from the complete ones only in degree, and the difference is slight 
and without practical importance except, perhaps, in the liability to an 
error in diagnosis because the symptoms are not so marked as in the 
typical cases. That is, the head is not so far removed from its place ; 
it is displaced forward rather than forward and inward. On the other 
hand, pain is much more severe and persistent, presumably because the 
ligaments are kept upon the stretch instead of being torn. 

The injury may be produced by direct or indirect violence, a blow 
upon the outer and upper part of the shoulder or hyperabduction of 
the arm, or by muscular action. When produced by direct violence 
the displacement is usually in a direction that is only sufficiently 
inclined downward to enable the head to pass below the coracoid pro- 
cess ; in a case reported by Kronlein l and in one of mine 2 the blow 
was received from above upon the acromion and only dislocated the 
humerus after it had broken that process. The extent of the displace- 
ment inward is affected partly by the force of the blow and the extent 
of the laceration of the capsule, and partly by the contraction of the 
muscles that adduct the limb. 

Dislocations by indirect violence are the most common, the force 
acting to produce hyperabduction of the joint. 3 

Hvperabduction acts by bringing the outer side of the upper end of 
the humerus into contact Avith the edge of the acromion and thus cre- 

1 The latest is a paper by Ross : Surgery, Gynec. and Obst., 1909, p. 168. 

2 Kronlein : Deutsche Chirurgie, Lief. 26, p. 14. 

3 For details see previous editions. 

4 Hyperabduction of the joint must be distinguished from that of the limb. The 
former can take place even while the elbow is below the level of the shoulder, for it 
is determined by the relations between the humerus and the scapula ; and as the 
scapula is freely movable the position of the limb (with reference to the body) , when 
the limit of motion in the joint is reached, varies with that of the scapula. 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 



575 



ating a new centre of motion for the continued movement, the effect of 
which is to cause the head of the humerus to descend and rupture the 
capsule in its inner and lower portion. After this rupture has taken 
place and the upward movement of the elbow has ceased, the contrac- 
tion of the muscles, the deltoid, pectoralis major, and latissimus dorsi, 
draws the head of the humerus inward past the anterior lip of the gle- 
noid fossa, and then when the elbow is lowered the head rises along the 
inner side of the joint, for the untorn outer and anterior portion of the 
capsule is made tense and, by thus preventing the descent of the portion 
of the bone to which it is attached, compels the movement to take place 

Fig. 289. 




Subcoracoid dislocation on a cadaver : showing rupture of lower part of the subscapularis. 

(B. Anger.) 

about this portion as a centre. As the first new centre of motion at 
the edge of the acromion determines, in connection with the muscles, 
the primary displacement, so the second new centre on the humerus 
at the outer and anterior attachment of the capsule determines the 
secondary displacement and the final position of the head of the bone 
and the attitude of the limb. 

Muscular action, the contraction of the muscles of the individual 
himself, can produce a dislocation either by drawing the head of the 
bone directly out of its socket, or, much more commonly, by creating 
conditions of leverage and momentum similar to those existing in the 
production of dislocations by indirect violence. Jn many of the re- 
ported cases it is difficult to recognize the mechanism of the injury. 
The least questionable examples of dislocation effected by the direct 



576 DISLOCATIONS. 

traction of the muscles are those in which the injury has occurred 
during a convulsion. A considerable number of such have been 
reported ; in one quoted below (Pollosson, page 563) the limb seems 
to have been in the position of inward rotation at the moment of dis- 
location. The examples of the other kind are numerous and varied, 
and the explanation is usually simple. A painter raises his arm 
to work upon a ceiling, an artilleryman to throw a shot, a patient 
lying in bed to free its curtain caught under the pillow, a woman to 
grasp an object hanging on the wall ; in such cases hyperabduction of 
the joint seems to be the probable cause. In others hyperabduction 
can only be invoked on the supposition that the contraction of the del- 
toid has lowered the acromion, the arm being fixed in a position below 
the shoulder, as in Bichat's case of the notary who dislocated his 
shoulder in an attempt to raise a heavy book from the floor, or in Volk- 
mann's of a woman who tried to lift a heavy pot from a shelf at the 
height of her shoulder, or Malgaigne's athlete who tried suddenly to 
lift a man kneeling in front of him, or Duplay's very muscular patient 
who stumbled while descending a staircase and threw out his arm to 
save himself from falling but touched no object with it. 

In other cases the influence of muscular action is entirely indirect. 
Thus, Rickert 1 tells of a very muscular man twenty-five years old who 
received a subclavicular dislocation by resting his hand against a wall 
over his head and sneezing. Bardenheuer mentions a similar case 
observed by Saponi. In such a case the mechanism is essentially the 
same as in that, for example, in which a man supported himself with 
his arms outstretched against a wagon to receive a sack of grain which 
another threw down upon his back and thereby dislocated both shoul- 
ders. 

It is impossible in most cases to determine the exact position and 
attitude of the limb at the moment the dislocation occurs, and the rela- 
tive parts taken by abduction, rotation, muscular action, and direct 
impulsion in its production. At present it can only be said that every 
one of the four has proved sufficient by itself, and that they have been 
found to co-operate in varying degrees. 

Pathology. The capsule is torn at its inner and lower portion between 
the tendon of the subscapularis and the triceps, and the rent extends 
usually along the inner and lower border of the glenoid fossa for half, 
sometimes even two-thirds, of the entire periphery. In other cases 
the rent extends outward and backward, rather than upward, and near 
the insertion of the capsule upon the humerus. Exceptionally, the 
rent is very small, or may even be entirely lacking, its place being 
sometimes taken by the stripping up of the continuous periosteum 
from the inner side of the neck of the scapula. Eve 2 reported a case 
of subcoracoid dislocation in which the capsule was untorn, but was 
separated from the anterior border of the glenoid fossa, remaining con- 
tinuous with the periosteum which was stripped up from the costal 
surface of the scapula. On the posterior surface of the head of the 

1 Rickert : Maryland Medical Journal, 1883-84, vol. x. p. 339. 

2 Eve : Transactions Pathological Society of London, 1880, vol. lxiii. p. 317. 



PLATE LII 




Old Dislocation of Shoulder. 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 577 

humerus was a deep vertical indentation made by impact against the 
anterior margin of the glenoid fossa. An almost identical case was 
shown to the London Pathological Society by D'Arcy Power. 1 In 
1880 I presented to the New York Surgical Society the shoulder- 
joint of an old man who had died of pneumonia a week after he had 
dislocated his shoulder. The dislocation was well marked, and reduction 
was effected with the aid of ether. The joint was opened from behind, 
and the capsule was found untorn ; the tendon of the subscapulars was 
partly detached at its insertion, but at no point throughout its entire 
thickness, and the upper facet of the greater tuberosity was broken off 
in several pieces, but not widely separated. 

The subscapulars muscle is sometimes simply pressed inward and 
separated from the scapula by the interposed head of the humerus, but 
in many cases it is torn more or less widely from its lower border 
upward, and its upper portion may lie upon the head of the humerus 
and separate it from the coracoid process. Occasionally, instead of 
being ruptured, the muscle is torn away from its attachment to the 
humerus, perhaps bringing with it the lesser tuberosity. I have seen 
one case in which the head passed beneath the tendon and then to its 
inner surface, so that division of the tendon was required to effect 
reduction. 

The supraspinatus is sometimes, probably often, torn from its attach- 
ment to the humerus, and the same is true in a less degree of the infra- 
spinatus, and occasionally even of the teres minor. 

The teres major is sometimes slightly 
torn, apparently by the partial passage of 
the head of the humerus between it and 
the subscapularis. 

The anterior edge of the glenoid fossa is 
occasionally broken off, and detachment of a 
portion of its nbro-cartilaginous rim seems 
not infrequent ; it is sometimes pushed 
away to some distance, bringing with it subcoracoid dislocation : to show 
the periosteum of the scapula. The aero- ^ e * ifferent deg J.T of ; otat | on of 

. r , . , i .. ill the humerus indifferent positions. 

mion and coracoid process have both been 

found broken, but such injury appears to have been purely incidental 

and should be classed as .a complication. 

The head of the humerus lies against the edge of the glenoid fossa, 
or further back against the side of the neck of the scapula, and either 
close up against the beak of the coracoid process behind the coraco- 
brachialis and the short head of the biceps, or lower down at a distance 
determined by its relations to the subscapularis and by the tension of 
the untorn portion of the capsule. It may lie largely on the outer side 
of the coracoid process, or immediately below it, or it may pass entirely 
to its inner side (intracoracoid dislocation), and it may be in outward 
or inward rotation (Fig. 290) or in any intermediate attitude. 

As has been already said, avulsion of the tuberosities may take the 
place of laceration of the muscles attached to them ; this has been 
rarely noted of the lesser tuberosity, but frequently oi' the greater 

1 D'Arcy Power ; Lancet, November 24, tSSS. 

37 




578 



DISLOCATIONS. 



and especially of its upper and middle facets. Yon Thaden, 1 who 
made a study of this feature, found that the upper and middle facets 
were each sometimes torn off separately, but the lower one only in 
connection with the other two. The complication is of importance 
because of the consequent loss of the control of the attached muscles 
over the humerus and the consequent exposure to recurrence of the 
dislocation (see Chapter XXIX.), and because it opens the way for 
the escape of the long tendon of the biceps from its groove and its 
interposition between the humerus and its socket in such a way as to con- 
stitute a serious obstacle to reduction. In the specimens Von Thaden 
examined he found the tendon thus interposed three times. Korte 2 
reported a similar case in which the tendon had slipped entirely out 
of its groove and was wound around the outer and posterior side of 
the head. Graessner 3 found the greater tuberosity broken 24 times in 
48 dislocations, but apparently in many of them the fragment was only 
a small scale of bone, practically an avulsion of the tendon. 

Fig. 291. 




Subcoracoid dislocation of the left shoulder. 



When the tuberosity or a portion of it is thus broken off, the frag- 
ment lies over or in the glenoid fossa, and the broken surface of the 
humerus rests against the inner surface of the neck of the scapula or 
engages the edge of the fossa. The upper and outer portion of the 
capsule thus separated from the humerus may remain interposed be- 
tween the head of the humerus and its socket and prevent reduction. 
After reduction of the dislocation the tuberosity unites with the 
humerus with more or less irregularity and deformity. 

1 Von Thaden: Arch, fur klin. Chir., vol. vi. p. 67. 

2 Korte : Ibid., vol. xxvii. p. 747. 

3 Q-raessner : Veroff aus dem G-ebiete des Militar-Sanitats, Hft. 35, p. 180. 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 579 

Except in connection with fracture of one or the other tuberosity 
the long tendon of the biceps is rarely dislocated, but it is sometimes 
torn away from its insertion or ruptured. 

In some specimens of old unreduced dislocation a vertical groove has 
been found on the articular surface of the head of the humerus which 
was thought to have been caused by prolonged contact with the edge 
of the glenoid fossa. Malgaigne, who took a special interest in the 
specimens as supposed examples of incomplete dislocation, suggested 
that the groove might have been caused at the time the injury was 
received by the forcible impact of one bone against the other. It is 
interesting to find that this suggestion has been confirmed by autopsy in 
Eve's and Power's cases mentioned above and by two specimens of 
recent dislocation preserved in the Museum of the University of Edin- 
burgh and reported in an interesting and valuable paper by Caird, 1 and 
by one reported by Broca and Hartmann ; 2 the indentation lay wholly 
or in part along the junction of the head and shaft above and behind the 
greater tuberosity, was from one to one and a half inches long, and 
from one-quarter to one-half an inch deep, and accurately fitted the 
inner lip of the glenoid fossa. The suggestion that the causation of 
fracture of the anatomical neck may be referred to the same mechanism 
seems very plausible. A similar indentation adjoining the lesser tuber- 
osity is reported by Pollosson 3 in a double dislocation by muscular 
action — convulsions of eclampsia. The position indicates that the 
limbs were in inward rotation at the moment of dislocation. 

The axillary vessels and nerves are pressed inward and are some- 
times injured. 

Symptoms and Diagnosis. The description of the symptoms will be 
made simpler by limiting it at first to those commonly found in the 
medium displacements, and subsequently indicating the differences or 
modifications peculiar to the exceptional grades and conditions. 

The patient sits with his trunk inclined toward the injured side, and 
supports the forearm with the other hand. The shoulder is flattened 
on the outer side so that the line of the deltoid runs straight down 
from the acromion and makes a more marked angle with the arm at 
its insertion than is usual. The anterior fold of the axilla lies lower, 
further from the clavicle than its fellow of the opposite side, and its 
creases appear deeper, as if the arm were applied more closely against 
the chest, and the outer part of the subclavicular fossa appears full. 

The elbow stands a little away from the side and can be easily 
abducted, but any attempt to bring it nearer the side causes pain and 
is resisted ; it may be in the axillary line, or in front of or behind it. 
When the elbow is flexed at a right angle the forearm is directed for- 
ward and inward ; its direction can be passively changed to either side, 
but not freely. The hand cannot be brought to the opposite shoulder. 

Voluntary movements of the dislocated joint are declared by the 
patient to be impossible, and pain is complained of in the shoulder, 
sometimes extending down the arm. 

1 Caird: Edinburgh Medical Journal, February, 1887. 

2 Broca and Hartmann: Bull, de la Soc. Aunt..' L890, No. 14. 

3 Pollosson : Rev. de Chir., November, 1SSS, p. 927. 




580 DISLOCATIONS. 

If the axis of the arm, viewed from in front, is prolonged upward 

by the eye it will be seen to pass to the inner side of the glenoid 

cavity, and if the fingers are firmly pressed 

Fig. 292. against the anterior wall of the axilla in the 

line of this prolongation and a little below the 

coracoid process they will encounter the firm 

<..• " \~ yW resistance of a solid body ; palpation shows 

this body to be globular, and if it can be 
grasped between the thumb and finger, or if 
the finger can find some projection on its sur- 
face, it will be found to share in slight move- 
ments of rotation communicated to the arm by 
the other hand of the surgeon. 

If now the head of the humerus is sought 

Diagram to show the effect for h Y palpation in its normal position it will 

of position upon the apparent not be found there ; the fingers can be pressed 

length of the arm in disioca- j n deeply under the acromion from the outer 

tion of the shoulder. A, aero- -i ,i , n ,1 • 

mion; b, lower end of hu- Slde '> m tlie outer margin of the acromion IS 
merus. . prominent and can be easily traced. This is 

marked when the limb is abducted. 

If the elbow be further abducted and the surgeon pass his fingers 
well up into the axilla he can there feel the head of the humerus more 
or less distinctly according as the displacement is low or high. 

If the distance be measured from the outer margin of the acromion 
to the external epicondyle of the humerus or the olecranon, it will 
usually be found somewhat greater, perhaps half an inch, on the 
injured than on the uninjured side, but if successive measurements 
are taken as the arms are abducted the difference will disappear, and 
in complete abduction the distance will be greater on the opposite side. 
The reason for this is seen by a glance at Fig. 292. 

As in most other dislocations, the capital point in the diagnosis is 
the recognition of the head of the bone and the determination of its 
relations to the socket from which it has escaped. Ordinarily, both 
of these can be accomplished at the shoulder with ease and certainty, 
and the examination is difficult only when the patient is very fat or 
the parts much swollen. 

As the attitude and range of motion of the limb depend mainly 
upon the tension of the untorn portion of the capsule, they will be 
modified when the capsule is freely torn. It is in such cases that the 
diagnostic sign so freely trusted, the inability to bring the elbow against 
the chest and to place the hand on the opposite shoulder, is lacking or 
only slightly marked. 

When the displacement of the humerus is less than usual, when its 
head rests upon the edge of the fossa, the "incomplete" dislocation 
of some writers, the symptoms are modified to this extent, that the 
flattening of the shoulder and the abduction of the elbow are less — 
the elbow may even lie close to the body, — and the head projects more 
directly in front, resting on the anterior edge of the glenoid fossa 
instead of dropping over to its inner side ; but the limb is equally 
fixed and incapable of being voluntarily moved. The pain also is 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 581 

greater. It has occasionally happened that the dislocation has been 
reduced by the manipulations used to make the diagnosis. 

Treatment. The treatment will be described in connection with that 
of the following variety. 

2. Intracoracoid Dislocations (Subclavicular Dislocations). 

To avoid misapprehension I repeat that the term " intracoracoid " 
was applied by Malgaigne to the class of cases which he deemed of 
most frequent occurrence, comprising two-thirds of the forty-nine 
cases of shoulder dislocation observed by him at the Hopital St. Louis, 
those in which the head of the humerus is so placed that from one- 
third to two-thirds or three-fourths of its transverse diameter lies to 
the inner side of the coracoid process. Most of such cases are now 
habitually spoken of as " subcoracoid," and the terms intracoracoid 
and subclavicular are restricted to those cases in which the bone is 
displaced still further inward. As between " intracoracoid" and 
"subclavicular" thus employed, I prefer the former name because it 
contains that of the anatomical landmark the relations to which form 
the basis of the classification. 

The injury may be produced by direct violence received upon the 
outer aspect of the shoulder or by hyperabduction of the arm. The 
essential causative feature of the variety, as compared with the sub- 
coracoid, is that the action of the original violence is prolonged, or 
that the secondary cause exaggerates the secondary displacement 
upward and inward. After a primary displacement forward and down- 
ward by abduction of the limb, anything that forcibly presses or 
draws the arm inward, such as pressure inward against the elbow, or 
the contraction of the deltoid and pectoralis major, may effect this dis- 
placement if the head of the bone has passed under the subscapularis, 
or if this muscle has been sufficiently torn. The head of the humerus 
lies against the wall of the chest, or rather against the serratus mag- 
nus, on one side, and against the costal surface of the neck of the 
scapula on the other. The subscapulars usually is widely torn ; in 
McNamara's case, quoted by Malgaigne, 1 it was untorn, and the head 
of the humerus had stripped it away from the scapula and had risen 
above its upper border, lying against the root of the coracoid pro- 
cess. No muscle or tendon was torn. In one of my own the head 
of the bone had passed beneath and entirely to the inner side of the 
subscapularis. 

The capsule is extensively torn, and the greater tuberosity usually 
broken off in whole or in part and lying in the glenoid fossa. 

The head of the humerus passes behind the muscles arising from 
the coracoid process (in one recorded case, Roser's, 2 in front of the 
coraco-brachialis and biceps and behind the pectoralis minor) and 
occasionally is partly interposed between the contiguous borders of the 
deltoid and pectoralis major, being then subcutaneous. It may lie 
immediately under or a little behind the clavicle, in one ease (Meyer) 

1 Malgaigne : Loc. tit., p. 525. 

2 Roser: Arch, fur phys. Heilkunde, 1844, p. 582, The dislocation had lasted for 
seven years, and many attempts had been made to reduce it. 



582 



DISLOCATIONS. 



it even projected above and behind it, and it has usually been found 
rotated inward. 

The long tendon of the biceps is broken, or displaced across and 
beyond the fractured surface left by the avulsion of the greater 
tuberosity. 

The main vessels and nerves lie rather behind the head than between 
it and the wall of the chest. 

Symptoms. The attitude of the patient and the general appearance 
of the shoulder are the same as in the subcoracoid variety ; the details 
differ mainly in degree, some being less, others more, marked. The 
flattening of the shoulder is greater, as is also, in some cases, the ful- 
ness of the subclavicular fossa, but this fulness is nearer the median 
line. The elbow may lie near the side, even in contact with it; the 
axis of the arm prolonged upward in front passes well to the inner 
side of the coracoid process. The fingers cannot be passed between 
the head of the humerus and the chest-wall, consequently only the 

Fig. 293. 





Intracoracoid dislocation. 



shaft and lower portion of the head can be felt through the axilla ; but, 
on the other hand, the lower anterior edge of the glenoid fossa and the 
neck of the scapula can sometimes be felt behind the shaft. 

Abduction of the limb is not always easy, and is effected by eleva- 
tion of the scapula rather than by movement of the humerus upon it. 
Differences in length, when the arm is dependent, are less constant 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 583 

and marked than in the preceding variety, but if the arm can be 
abducted upon the scapula the shortening is then greater. 

The dislocation can be transformed into a subcoracoid by traction 
downward and outward. 

Occasionally 1 the dislocated arm is fixed in the position of complete 
horizontal abduction (Fig. 294). Such are doubtless cases in which 

Fig. 294. 




Intracoracoid dislocation, with arm fixed in horizontal abduction. (Babdenheuer.) 

the head has left the socket at a low point while the arm was widely 
abducted. (See Subglenoid Dislocations and Luxatio erecta, Chapter 
XLIII.) 



Treatment of Anterior Dislocations! 

(See, also, Chapter XXXIII.) 

Obstacles to the return of the head of the humerus to its socket may 
be created by the tension of portions of the capsule which oppose its 
movement toward the socket, except in certain attitudes of the limb, 
by the approximation of the sides of the rent in the capsule through 
which it has passed, by the interposition of portions of the capsule or 
of the tendon of the biceps, by its engagement behind the edge of the 
glenoid cavity or the coracoid process, by the contraction or rigidity of 
the muscles and the swelling of the soft parts, and exceptionally by 
the interposition of the tendon of the subscapularis (see above). Those 
which are most frequently concerned are the opposition of the anterior 
portion of the capsule and the contraction of the muscles. 

If the portion of the capsule which extends from the base of the 
coracoid process and the outer, or posterior, edge of the glenoid fossa 
to the greater tuberosity and posterior portion of the humerus, includ- 
ing the coraco-humeral ligament, remains untorn, it is stretched down- 
ward and forward across the glenoid fossa, and, being drawn tight by 
the weight of the elbow, it holds the head of the humerus against the 
scapula. If now the elbow is raised, the capsule is thereby relaxed, 
and the abducted limb can be easily drawn outward. 

If the capsule is so freely torn away from the humerus on the outer 
side that it falls down between it and the glenoid fossa, it cannot be 

1 Rardenheuer: Deutsche Chirurgie, Lief/ (>;> a, p. ;U7. 



584 DISLOCATIONS. 

lifted out of the way by manipulation of the arm because its separation 
is so complete that it is no longer affected by the position given to the 
latter. It may, perhaps, be pushed out of the way by the returning 
bone, but that is a matter of chance rather than of skill. Probably, 
full abduction of the arm followed by traction would be most likelv to 
accomplish the object under such circumstances. 

Dislocation and interposition of the tendon of the long head of the 
biceps occurs only with avulsion of the greater tuberosity, arid not 
always then, for it may, instead, be ruptured. Even when interposed, 
the tendon may be fairly expected to have preserved its relations with 
the lower part of the bicipital groove and sheath, and consequently to 
be still somewhat under control by the humerus. By elevating the 
arm and flexing the elbow it will be relaxed and raised toward the 
upper part of the joint, leaving space below for the head of the bone 
to pass back under it. 

Abduction of the arm and external rotation are, then, the means by 
which the most common obstacles created by the capsule are to be 
avoided. 

The muscles oppose reduction by their contraction excited by pain 
or the fear of pain ; this can sometimes be avoided by taking the patient 
unawares, or by fatiguing the muscles, and always bv anaesthesia. A 
certain anxiety connected with resort to the aid of anaesthesia has arisen 
from the fact that a disproportionate number of deaths caused by chloro- 
form have occurred in the reduction of dislocations (see p. 445), but I am 
not aware that death has ever followed the use of ether under such cir- 
cumstances. There are many reasons why reduction should be made, 
when conveniently practicable, without its aid, but I never hesitate to 
avail myself of the aid of ether in preference to the employment of 
long-continued, forcible, or painful traction, even in recent cases. In 
those of long standing, in which adhesions must be broken, the capsule 
retorn, and the shortened muscles elongated, it is indispensable. 

Reduction in recent cases is usually easy, and it has been safely 
accomplished after the lapse of many weeks and even months. It is 
impossible to fix a period after which reduction by traction should no 
longer be attempted ; each case must be judged by itself. Serious, even 
fatal, accidents have followed the attempt so often that the surgeon is 
fully justified in advising abstention on the ground that the risk is too 
great to be taken. Personally, I prefer in a doubtful case to expose 
the joint by incision and liberate the head of the humerus by rotation 
and traction. (See Chapter XXXIII.) 

In all the methods in which forcible traction is made upon the arm 
success depends largely upon efficient fixation of the scapula. When 
the traction is made by specially constructed apparatus the counter- 
extension is effected by a ring or crutch arranged to bear against the 
scapula, but when it is made by the hands of assistants the scapula 
may be fixed by a split band through which the arm is passed. In 
most cases in which only moderate traction is made a simple band 
about the chest is sufficient, or the pressure of the surgeon's foot or 
hand against the side of the chest or the acromion. 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 585 

Direct Reposition. Tin's method, the use of which can be traced 
back to the time of Avicenna, has been of late especially recommended 
by Richet and Von Pitha. It is often successful in recent cases in 
which the displacement and muscular contraction are not great, and 
especially when aided by anaesthesia. The arm, somewhat abducted, 
is supported by the side, and the surgeon, placing his ringers in the 
axilla on the under and inner side of the head of the humerus, and 
his thumbs upon the acromion, seeks to press the bone directly into 
place. Or the position of the hands may be reversed, the thumbs 
being placed in the axilla and the fingers upon the acromion. Or, the 
patient being seated, the surgeon supports the flexed elbow upon his own 
forearm, gets his fingers around the head of the humerus in the axilla, 
and presses it toward the glenoid cavity while he steadies the scapula 
with the other hand. 

Traction Downward and Outward with Coaptation. In its simplest 
form, one that is successful in a large proportion of cases, especially 
with the aid of anaesthesia, the method is practised as follows : The 
patient is placed upon a bed and counter-extension is provided by a 
band passed around his chest and made fast to a support on the 
sound side. If anaesthesia is used the weight of the body is usually 
sufficient for counter-extension, and this band can be dispensed with. 
The surgeon grasps the arm above the elbow and pulls steadily down- 
ward and outward at first, and then slowly changes the direction by 
increasing the abduction until the arm is nearly or quite at right angles 
with the body, while, at the same time, he rotates the arm outward. 
Or the traction is made by an assistant, and the surgeon, standing 
beside the patient, watches the movement of the head of the humerus, 
and when it has approached the joint he presses it upward into place 
with his fingers or thumb, making counter-pressure on the acromion. 

If anaesthesia is not used, or if more force is used, the scapula may 
be fixed by bands passing over and under the shoulder or by pressure 
against the edge of the acromion. Or the patient can be laid on his 
back on the floor, and the surgeon seated beside him places his foot 
against the side of the chest or the edge of the acromion and draws the 
arm directly outward. 

It is desirable that the elbow shall be kept partly flexed to relax the 
biceps, and also, if the surgeon himself is making traction, to enable 
him to rotate the limb inward when the head has been brought close 
to its socket, since this manoeuvre is sometimes an efficient substitute 
for direct pressure upon the head. 

I 1 have of late (1899) employed with uniform success in about a 
dozen cases a method of making this traction which is easy, expedi- 
tious, and apparently safe. A round hole six inches in diameter is 
made in the middle line of a canvas cot about eighteen inches from one 
end, and through this hole the injured limb is passed so as to hang 
vertically downward, the patient lying on his side on the cot (Fig. 
295). To the limb, at the wrist or elbow, is attached a weight of 
about ten pounds, and the cot is raised upon blocks so that the arm will 
hang free of the floor. In a few minutes, never more than six in my 

1 Stimson : Med. Record, March ;?, 1900. 



586 



DISLOCATIONS. 



experience, reduction of the dislocation takes place quietly and without 
pain during the waiting. Instead of a cot, the patient might perhaps 
be put upon two tables placed end to end so that the body would rest 
on one and the head on the other, the arm hanging down between, but 
possibly the lack of snug support of the shoulder, and the consequent 
muscular effort to maintain the position, would interfere with success 
or at least delay it. Continuous traction by India-rubber or a weight 
aud pulley, as described on page 466, acts in the same gentle manner. 
Another modification is the so-called " pendel-methode," which occu- 
pies a position intermediate between the above and the following 
method, hyper-elevation of the arm, and in which the weight of the 
patient's body is used to make the traction. The patient is laid upon 

Fig. 295. 




Reduction of anterior dislocation of the shoulder. 



the floor on the sound side, and an assistant, standing upon a stool, 
grasps the dislocated arm and lifts the shoulders from the floor while 
the surgeon presses the head of the bone toward its socket. If a greater 
weight is needed another assistant raises the feet so that the body is 
wholly oif the floor, or presses downward against the side of the chest. 
If a sufficiently robust assistant is not at hand, or if the effort is to be 
prolonged, the suspension may be made by means of a rope attached to 
the arm above the elbow. Bardenheuer says that Simon reduced by 
this means a dislocation that had existed for a year and three-quarters. 
Traction Upward. In this method the arm is raised beside the head 
and drawn upon while counter-extension is made by the hand or 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 587 

foot upon the top of the shoulder. Duplay, following Malgaigne, 
speaks of it in rather exaggerated terms as the only rational method, 
because it relaxes all the muscles. The difference between it and trac- 
tion at right angles to the body is more apparent than real, because the 
further elevation of the arm is effected by a change in the position of 
the scapula upon the chest, without change in its relations to the 
humerus. The method which was known to Celsus and practised by 
Brunus in the thirteenth century, was extensively used in England in 
the last century, but is more particularly connected with the name of 
Mothe in France, and of Kluge in Germany. Malgaigne says that 
he himself reinvented it for the fourth or fifth time in 1828 as the 
result of experiments upon the cadaver. It has commonly been com- 
bined in practice with some form of the method next to be described, 
the bascule of the French and German authors, that in which the head 
of the bone is pressed outward by placing a fulcrum high up in the 
axilla and then swinging the elbow in toward the body, and has also 
been frequently supplemented with external, followed by internal, 
rotation. 

In its simplest form, as described by Bransby Cooper, the patient is 
placed upon his back on the bed or table, and the surgeon sitting beside 
his head draws the dislocated arm upward with one hand and fixes the 
scapula with the other ; the counter-extension may be aided by a long 
bandage or towel passing over the shoulder and fixed by both ends to 
the foot of the bed. After reduction has taken place, and while the 
arm is being lowered, the head of the humerus should be held in place 
by direct pressure upon it. 

Malgaigne's plan, when more force was needed, was to rest the 
patient on the floor, and lift the arm directly upward with both hands, 
counter-extension being made by the weight of the body and aided, if 
necessary, by pressure made upon the acromion by an assistant. If 
this failed and he wished to try more force before resorting to the 
bascule, he made the patient stand beside a door and raised the arm to 
a vertical position by means of a strong band made fast at the wrist or 
elbow and carried over the top of the door ; then the patient was 
directed to bend his knees until the weight of his body should be 
entirely supported by the dislocated arm, and, in addition, the surgeon 
contributed his own weight by clasping his hands over the patient's 
acromion and kneeling beside him. The addition, proposed by Lacour l 
in 1847, of external and internal rotation to the vertical traction, has 
added to its efficiency. 

The chief objection to this method is that mentioned in connection 
with the preceding one, the risk of injuring the main vessels in the 
axilla by unduly stretching them around the head of the humerus, 
and it is even greater here because the elevation, or abduction, 
is made without preliminary traction to bring the head nearer the 
socket. 

Another objection is that it is likely to increase the laceration oi^ the 
capsule and of the subscapularis and thereby promote recurrence of the 
dislocation. 

1 Lacour: Mem. de Chirurgie, 1817, vol. i. p. 3S7. 



588 D1SL CA TIONS. 

Traction with Leverage. This method differs from that of traction 
downward and outward in the addition, or the substitution for direct 
coaptative pressure by the hands, of a leverage movement in which 
the head of the bone is forced outward by the adduction of the limb 
over a fulcrum placed in the axilla. The fulcrum is usually the 
closed fist or the heel. 

When the hand is used traction is made outward and downward by 
an assistant, and when the head of the bone has been moved sufficiently 
far the surgeon places his closed fist well up in the axilla, and the 
assistant, still maintaining the traction, swings the arm toward the side 
(adduction), sometimes combining with it moderate rotation. 

The Heel in the Axilla. This method, generally known as Sir Astley 
Cooper's, but really dating back to the time of Hippocrates, was in 
very general use in England and America until quite recently. It is 
unfortunately responsible for not a few more or less serious injuries to 
the bloodvessels and nerves of the axilla. 

The patient is placed upon his back on a bed or sofa and a towel or 
stout bandage made fast to the arm above the elbow. The surgeon, 
facing him, seats himself upon the side of the bed and places the heel 
of one foot, from which the shoe has been removed, well up in the 
axilla against the head of the humerus and then makes traction down- 
ward upon the towel and maintains it until the bone is felt to slip into 
place. Remembering that under these conditions traction upon the 
humerus is directly transmitted to the scapula through the already 
tense capsule, it seems probable that the method owes its efficiency to 
the action of the heel as a wedge, which by being forced in between 
the thorax and the humerus presses the latter directly outward. If 
the traction is made at first in a direction inclined away from the body, 
and then brought more nearly parallel to it, the mechanical effect is 
the same as when the fist is used as above described. 

It may be proper to employ this method if no more force is used 
than can be exerted by the surgeon himself, although accidents have 
happened even under such circumstances, but it is certainly dangerous 
and improper to employ it with the pulleys or assistants, and still more 
so to substitute an iron plug for the heel as recommended and prac- 
tised by Skey. The large vessels and nerves lie upon the inner side 
of the head of the humerus and are exposed to be compressed between 
it and the heel and thus directly bruised or so held fast that they may 
be overstretched and torn as their distal portions are drawn downward 
in the sliding of the soft parts of the arm toward the elbow. 

Forcible Traction. If more forcible traction is needed than can be 
made in the methods already described, resort should be had to the 
pulleys or specially constructed apparatus. The pulleys are made fast 
to the arm above the elbow by a broad leather band buckled tightly 
around it or by a strap or band made fast by several turns of a wet 
bandage. As a further precaution against slipping the forearm should 
be bandaged and the elbow fixed at a right angle. It is also advisable 
to interpose a dynamometer between the pulleys and the limb to indi- 
cate the amount of force that is being employed, and a pair of " liber- 



ANTERIOR DISLOCATIONS OF THE SHOULDER 



580 



ation forceps" to allow the traction to be suddenly relaxed and the 
position of the arm changed. 



Fig. 296. 




Reduction with the pulleys : 4, dynamometer ; 6, " liberation forceps." (Duplay.) 

The special instruments, of which the most elaborate and ingenious 
are made in France, are, in the main, modifications of the "adjuster" 
invented by Dr. Jarvis, of Portland, Connecticut. They consist of 
two bars movable upon each other by a rack and pinion, one of Avhich 
is made fast by a leather bracelet to the lower part of the arm, and the 
other to a ring or crutch that fits against the scapula. A dynamom- 
eter indicates the force exerted, and a catch sets it instantly free at 
will. The instruments are expensive, the occasions for their use are 
rare, and the method is dangerous. 

Reduction by Manipulation. (Rotation.) It has been already men- 
tioned that rotation of the arm has long been used in connection 
with the various methods of extension to effect reduction, and it also 
appears that from time to time men have sought to reduce, and some- 
times with success, by moving the limb in various directions without 
the aid of much traction, but it is only within the present century that 
methods of manipulation founded upon a correct appreciation of the 
obstacles and of the means by which they may be overcome have been 
devised and practised with intelligence and success. Rotation inward 
was long employed as the final manoeuvre to turn the head of the bone 
into the socket after it had been brought opposite it by traction, and it 
still constitutes the final step in the pure manipulative method. Exter- 
nal rotation during traction was first employed under the influence of 
various ideas concerning the part taken by the muscles in opposing the 
return of the bone, or to dislodge the head from its position behind the 
lip of the glenoid fossa ; then, in the light of more accurate knowledge 
of the influence of the untorn portion of the capsule, it became the first 
step in the methods of reduction without traction. 

Of these methods the one most highly esteemed and generally prac- 
tised is that recommended by Prof. Kocher, 1 of Bern. The follow- 
ing description is taken from one given at the Surgical Congress in 
London, and published by his pupil Ceppi in the Recur de Chirurgie } 
1882, ]). 831 : " In the subeoracoid dislocation the posterior portion 



1 Kocher : Berlin, klin 
Vortrage, No. 83, p. (ill. 



Wochenschrift, 1870. No. 9. and Volkmann 



ininiluny; klin. 



590 DISL CA TIONS. 

of the capsule and the tendons of the posterior scapular muscles which 
cover and strengthen it are untorn and are stretched over the glenoid 
fossa. The inferior portion of the capsule which forms the lower bor- 
der of the rent is also very tense. But the tension is greatest at the 
upper part of the capsule, and especially between the long tendon of 
the biceps and the upper border of the subscapulars, where it is 
reinforced by the fibres of the coraco-humeral ligament. This portion 
of the capsule is twisted in the dislocation, and stretched in the" form 
of a solid cord. If now the humerus is rotated externally until the 

Fig. 297. 




Kocher's method of reduction by manipulation : 1st movement, outward rotation. (Ceppi.) 

flexed forearm is turned directly outward, this cord will be at the same 
time rotated outward, the posterior part of the capsule w T ill be widely 
removed from the fossa, and the rent in the capsule w T ill gape ; but the 
head of the humerus will still remain solidly fixed against the anterior 
edge of the glenoid fossa because the upper and low r er portions of the 
capsule have not been relaxed by this movement. It is only when 
the elbow is carried forward and raised in the sagittal plane, while the 
arm is still held in external rotation, that the upper part of the capsule 
is seen to relax, and the head of the humerus, thanks to the tension of 
the lower portion which keeps it from moving forward, to enter its 
socket. Rotation inward then completes the reduction." 

The method may be formulated in detail as follows : Dislocation 
of the left shoulder. The patient is seated, and the surgeon, kneel- 
ing beside him, flexes his elbow at a right angle and presses it with 
his right hand against his side ; then, holding the elbow firmly in 
place, he slowly and steadily moves the wrist outward with his left 
hand (external rotation of the humerus) until the forearm stands 
directly outward from the side of the body ; if this is strongly re- 
sisted the pressure must be steadily maintained until the resistance 
yields. The evidence that the movement has accomplished what was 
expected of it is the appearance of greater fulness of the outer deltoid 
region ; if this does not appear the attempt will fail. Then, still main- 
taining the external rotation of the arm and the flexion of the elbow, the 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 591 

surgeon moves the elbow forward, or forward and slightly inward, until 
the arm is nearly horizontal ; during this movement the fulness of the 
outer deltoid region becomes more marked, and at its termination the 
manoeuvre is completed by rotating the arm inward and bringing the 
hand to the opposite shoulder. The bone may slip into place during 
the second movement, elevation of the elbow. Direct traction out- 
ward of the upper end of the bone by a bandage in the axilla is some- 
times helpful, and I have sometimes found it advantageous to make 

Fig. 298. 




Kocher's method of reduction : 2d movement, elevation of elbow. (Ceppi.) 

firm pressure downward at the elbow (traction in the long axis of the 
arm) during the movement of outward rotation. 

The method as thus described is applicable to those cases in which 
the displacement is neither very far inward nor low down, in short, 
to the higher forms of the subcoracoid variety ; and as it depends for 
its success upon the resistance of the untorn portion of the capsule it 
will fail whenever the capsule is very extensively torn. When the 
displacement is far inward or low, traction upon the abducted limb 
is more likely to succeed. 

Konig 1 modifies it for the lower anterior and subglenoid dislocations 
by making traction in abduction, rotating outward, and then adduct- 
ing. This is practically the same as the method described as traction 
downward and outward and generally known as Lacour's method by 
manipulation. 

Farabeuf 2 studied Kocher's method experimentally with a view to 
determine the mechanism by which its result was accomplished, and 
reached the conclusion that the efficient agent was the untorn posterior 
portion of the capsule, and that the upper portion, the eoraco-humeral 
ligament, had little or nothing to do with it. He showed, experi- 
mentally, that when this latter had been divided and the posterior por- 
tion left intact the manoeuvre would still effect reduction, but that when 
the posterior portion was divided and the upper portion left whole it 

1 Konig: Speciel. ChiruTgie, 3d ed., vol. iii. p. 40. 

2 Farabeuf: Bull, do la Sue. de Our., L885, p. 395. 



592 



DISLOCATIONS. 



failed, and that then the head of the humerus instead of being moved 
outward by the external rotation simply revolved about the longitu- 
dinal axis of the shaft. His explanation is clear and intelligible. 
According to it the approximation of the elbow to the side tightens the 



Fig. 299. 




Kocher's method of reduction : 3d movement, inward rotation and lowering of elbow. (Ceppi.) 



posterior portion of the capsule where it extends between the posterior 
lip of the glenoid fossa and the lower and back part of the neck of 
the humerus ; this prevents the posterior surface of the humerus from 
moving inward when the arm is rotated outward, and consequently its 
attachment to the humerus serves as the fixed point or centre about 
which the bone rolls outward, winding itself, as it were, upon the cap- 
sule. The elevation and adduction of the elbow, turning upon the 
same fixed point, then throws the head backward and further outward, 
and finally the internal rotation unwinds the capsule and leaves every- 
thing in place. 

The method is applicable to old as well as to recent cases, but the 
danger of breaking the humerus during the second step — outward rota- 
tion — must be borne in mind, especially in elderly patients. 

Schinzinger's method, the introduction of which appears to have ante- 
dated Kocher's, was in like manner based upon the persistence of the 
posterior portion of the capsule, but differed from Kocher's in the 
second and third steps of the manoeuvre. He rotated the arm outward 
until the hand was as far back as the elbow, and then either pressed 
the bone upward and outward into place by direct pressure, or turned 
it in by slow internal rotation while an assistant made pressure on the 
inner side of its head to prevent it from slipping back into the position 
from which it had been removed by the outward rotation. The method 
is favorably spoken of by several of the later German writers, and is 



ANTERIOR DISLOCATIONS OF THE SHOULDER. 593 

thought to be especially useful in rupturing the adhesions of old dislo- 
cations without the risk of injury to the vessels or nerves. 

Circumduction, sometimes known as Heine's method, in which, after 
fixation of the scapula as for traction, the arm is slowly abducted, raised 
to the side of the head, inclined slightly backward, and then brought 
forward and downward across the face and chest, has been recom- 
mended and used in old dislocations ; it is undoubtedly efficient in 
breaking up the adhesions, but it is a rough, uncertain, and dangerous 
plan, and should be condemned. 

To recapitulate, the treatment of a recent anterior dislocation of 
average displacement may be thus summed up : Kocher's method may 
first be tried ; if that fails, traction downward and outward by one of 
the various methods should be tried, the elbow not being raised higher 
than the shoulder, combined with direct pressure upon the head, or 
followed by adduction over the fist in the axilla. If these also fail, 
the patient should be etherized, and the attempt repeated. When 
those rare conditions are present which make reduction otherwise 
impossible — interposition of capsule or tendon of biceps or subscapu- 
laris — an open arthrotomy is justifiable if it can be done with proper 
precautions against infection. 

In older dislocations the same plan should be followed, and resort 
should be had to forcible traction only after other measures have failed. 

The signs of a successful reduction are the sound that is usually 
heard when the bone slips into place, the restoration of form and func- 
tion, and the diminution or cessation of pain. The sound is not always 
heard, and, on the other hand, a similar sound may be caused by the 
rupture of adhesions or by the slipping of the bones upon each other. 
Complete restoration of form is the best evidence ; this is to be deter- 
mined by an examination similar to that employed in making the 
diagnosis of a dislocation and by attention to the same signs. The 
reduction may be incomplete because of the interposition of a portion 
of the capsule, or because of the presence of tissues of new formation 
in the glenoid cavity. This incompleteness is shown by the abnormal 
projection forward of the head of the humerus under the acromion. 

After-treatment. 

After reduction has been obtained it is highly desirable that the 
arm should be immobilized for two or three weeks in a position 
that will favor the speedy repair of the lacerations of the capsule, 
tendons, and muscles ; otherwise the joint may remain in a con- 
dition that favors recurrence, and the patient may sutler much in- 
convenience or even disability in consequence. As the rent in the 
capsule is on the inner side, and as its edges are separated by external 
rotation of the limb, the head of the humerus should be directed 
toward the outer side (adduction of the elbow) and the arm should be 
kept rotated inward. These two indications are met by binding the 
limb to tjie body with the hand resting just below the opposite clavicle. 
Fixation may be made by a starch or plaster-of-Paris dressing or even 
by simple bandages, but the most convenient and effective dressing 



594 DISLOCATIONS. 

is a strip of adhesive plaster arranged as follows : beginning in front 
at the clavicle it is carried over the shoulder and down the back 
of the arm, then under the elbow to the back of the forearm, and 
along the latter and the back of the hand to and over the top of the 
opposite shoulder. A small pad of absorbent cotton or lint should be 
placed in the axilla and between surfaces of skin that are in contact. 
If the patient is unruly a second band may be placed circularly about 
the body and lower part of the arm. This dressing should be retained 
for two or three weeks, and the arm carried in a sling for a fortnight 
longer. If passive motion is made, abduction and external rotation 
should be avoided. 

For complications, accidents, prognosis, and the treatment of old 
dislocations, see Chapter XLIV. 



CHAPTER XLIII. 

DISLOCATIONS OF THE SHOULDER.— (Continued.) 

Downward Dislocations : Subglenoid, erecta, subtricipital — Posterior Disloca- 
tions: Subacromial, subspinous, upward dislocations. 

DOWNWARD DISLOCATIONS. 

1. Subglenoid. 

Under this title are here included those rare cases in which the 
head of the humerus is displaced directly downward upon the tendon 
of the long head of the triceps, and those more frequent ones in which 
it is engaged under the lower and inner edge of the glenoid cavity, 
and rests against the flattened upper portion of the axillary border of 
the scapula on the inner side of 

the tendon of the triceps. As Fro- 300. 

explained in connection with 
the classification given in the 
preceding chapter, the name is 
here restricted to a portion of 
those cases which are termed 
subglenoid by most English 
and American authors, to those, 
namely, in which the head of 
the bone is low in the axilla. 
By some the term is still further 
restricted in use, and is applied 
only to the first of the two 
forms above mentioned, those 
in which the head is displaced 
directly downward upon the 
tendon of the triceps. Although 
it is denied by some on theo- 
retical grounds that this form 
can exist, yet it must be ad- 
mitted not only as possible, but as having been actually observed, on 
the evidence of several observers who fully understood the point in 
dispute. Von Pitha (quoted by Bardenheuer) says that he had seen 
it only in cases in which he had the opportunity to examine the patient 
immediately after the accident, and before any movements had been 
communicated to the limb or attempts made to reduce. He believes 
that the head can be easily displaced from its new position, and moved 
upward and forward, the dislocation being thus transformed into a sub- 
eoracoid, by involuntary or communicated movements of the arm, or 




Subglenoid dislocation. 



596 DISLOCATIONS. 

even by muscular action. Tillaux ] observed this transformation in a 
case while he was preparing to make a cast of the limb. 

Two varieties, representing extreme displacements, and characterized 
by exceptional symptoms, the luxatio erecta and the subtricipital (?), 
will be separately described. 

This form of dislocation was studied experimentally by Malle, 2 
Goyrancl, 3 and Panas. 4 They found that if the scapula was fixed and 
the arm was firmly elevated, the head of the humerus presented 
through a large rent in the capsule between the subscapularis and the 
long head of the triceps, and that if the arm was then lowered the 
head would often return to its socket, but that if it was twisted out- 
ward while being lowered the dislocation would persist. The lower 
border of the subscapularis was always found torn and its untorn por- 
tion rested upon the upper surface of the head ; and Malle claimed that 
in order to produce the dislocation upon the cadaver it was necessary 
to divide the portion of the capsule between the acromion and the 
lesser tuberosity. 

The cause, with the single exception of Desault's doubtful case, in 
which the injury was said to have been produced by a fall upon the 
shoulder, has always been the forcible elevation of the arm, as in a fall 
through a narrow opening or upon the extended elbow, by a horse 
throwing up his head while being led by the bridle, or as in Goyrand's 
case of a woman who, having fallen to the ground, had her arm dislo- 
cated by a passer-by who sought to raise her. In one of Tillaux's 
cases a young girl dislocated her shoulder by suddenly raising her arm 
while playing at raquettes. 

The rent in the capsule in the specimens produced experimentally 
has always been comparatively small, and situated in the lower and 
inner portion between the triceps and the subscapularis, and differs 
from that of the subcoracoid form in not extending so far upward 
along the anterior edge of the glenoid cavity. In a specimen presented 
by Leroy 5 to the Societe Anatomique the lesions were identical with 
those produced experimentally. The upper part of the capsule, includ- 
ing the insertion of the supraspinatus and infraspinatus muscles, was 
torn away from the humerus, from the anterior border of the bicipital 
groove to the tendon of the teres minor, a distance of four centimetres ; 
in the lower portion was the usual rent, two and three-quarters inches 
long, extending from the tendon of the teres minor inward and then 
upward along the anterior border of the glenoid cavity. The head of 
the humerus lay upon the axillary border of the scapula one inch below 
the anterior border of the coracoid process, the limb being so far rotated 
outward that the internal epicondyle was directed forward, and the 
greater tuberosity rested against the anterior lip of the axillary border 
and the adjoining portion of the neck of the scapula. The subscapu- 
laris was pushed upw T ard and overlapped the head. In another reported 
to the same society by Bouygues, 6 the head of the humerus lay below 

1 Tillaux : Anat. topographique, p. 536. 

2 Malle: Bull, de l'Acad. de Med., Paris, 1838, vol. ii. p. 941. 
" Goyrand : Mem. de la Soc. de Chir., 1847, vol. i. p. 21. 

4 Panas: Diet, de Med. et Chir. pratiques, art. Epaule, p. 462. 

5 Leroy : Bull, de la Soc. Anatomique, 1844, p. 102. 5 Bouygues : Ibid., 1888, p. 581. 



DOWNWARD DISLOCATIONS OF THE SHOULDER. 



59' 



and in front of the glenoid fossa and beneath the untorn subscapularis, 
the anatomical neck resting on the axillary border of the scapula and 
the lower part of the fibrocartilaginous rim ; the upper portion of the 
greater tuberosity was broken off. 

In a case reported by Jossel l of subglenoid dislocation caused by a 
fall from the second story of a house, in which death followed on the 
second day in consequence of an associated fracture of the skull, the 
following conditions were found : The subscapular artery was entirely 
torn across. The head of the humerus lay between the partly torn sub- 
scapulars muscle and the triceps " upon the triangular surface of the 
lower border of the scapula directly below the glenoid fossa." The 
capsule was entirely torn from the humerus, the subscapularis was 

Fig. 301. 




Subglenoid dislocation. (From a photograph.) 

pushed upward, the edge of the glenoid fossa was a little broken at its 
widest part, and the upper and middle facets of the greater tuberosity 
were broken off, the line of fracture running into and opening the 
bicipital groove. 

In Sedillot's case, quoted by Malgaigne as of this kind, the condi- 
tions were quite exceptional ; abduction was so marked that the arm 
was held almost horizontal, the head of the humerus was situated half 
an inch below the glenoid fossa, resting against the scapula, but also 
engaged between the latissimus dorsi and teres major in front and the 
triceps behind. 

Apparently the failure of the head to rise as usual to the level which 

1 Jossel : Deutsche Zeitschrift fur Chirurgie, 1874, vol. iv. p. 124, 



598 DISLOCATIONS. 

would make the dislocation subcoracoid is due to the resistance of the 
untorn portion of the capsule on the inner side ; and the greater abduc- 
tion of the limb is due to this retention of the head at a lower level, 
for the untorn outer portion prevents the shaft from sinking unless the 
head correspondingly rises. 

Symptoms. The flattening of the outer portion of the shoulder, the 
prominence of the acromion, and the abduction of the elbow are all 
more marked than in the subcoracoid dislocation ; and the axis of the 
arm prolonged by the eye in front passes below and to the inner side 
of the glenoid cavity. Measured in partial abduction from the acro- 
mion to the elbow, the arm appears longer than its fellow, and this 
elongation may not give place in complete horizontal abduction to as 
much shortening as is found in the subcoracoid form. The head of 
the humerus can be plainly felt in the axilla, and is separated from the 
coracoid process by an interval of from half an inch to an inch. 

The differential diagnosis from subcoracoid dislocation is made by 
recognition of the position of the head below the glenoid fossa ; the 
corroborative symptoms are the more marked flattening of the deltoid 
and its angle with the arm and the wider abduction of the elbow. 

Treatment. Theoretically, the position of the head below the glenoid 
fossa suggests that traction should be made upward and outward, the 
elbow being raised above the shoulder, and this plan is generally recom- 
mended and usually successful. The objection to it is the added risk 
of doing injury to the bloodvessels in the axilla by overstretching them 
around the head of the humerus, as explained in the preceding chapter. 

It is prudent, therefore, that a trial should first be made of the 
method of direct reposition (p. 585), and, that failing, of traction in 
the direction of the arm as found, or with a little more abduction, fol- 
lowed by adduction while pressure outward and upward is made upon 
the head of the bone, or with the fist in the axilla. The reader is 
referred to the preceding chapter ibr the details. 

2. Luxatio Erecta. 

This striking dislocation, first described by Middeldorpf, and his 
pupil Scharm x who reported the former's two cases, is characterized 
by the marked elevation of the arm, the forearm usually resting on 
the top of the head, a position from which it cannot be lowered with- 
out causing great pain, and by the prominence of the head low in the 
axilla. Besides Middeldorpf 's two cases I have met with the descrip- 
tion or mention of six others by Busch, 2 Panas, 3 Lange, 4 Alberti, 5 
Hannson, 6 and Judd, 7 and a reference by Bardenheuer, 8 without 
details, to a case reported by Bertin and two cases reported by Meyer. 
Three cases have been admitted at the Hudson Street Hospital, but I 
saw only one of them. 

1 Middeldorpf: Clinique Europeenne, 1859, vol. ii., and Scharm, De nova humeri luxa- 
tionis specie. Dissert. Inaug. Breslau, 1859; quoted by Alberti, vide infra. 

2 Busch : Archiv fur klin. Chir., 1863, vol. iv. p. 30. 

3 Panas : Diet, de Med. et Chir. pratiques, art. Epaule, p. 405. 

4 Lange : New York Medical Record, 1879, vol. xvi. p. 400. 

5 Alberti : Deutsche Zeitschrift fur Chir., 1884, vol. xx. p. 475. 

6 Hannson : Centrabl. fur Chir., 1892. p. 18. 

7 Judd : New York Medical Journal, October 19, 1895. 8 Bardenheuer : Loc. cit., p. 303. 



DOWNWARD DISLOCATIONS OF THE SHOULDER. 599 

The only opportunity for direct examination of the parts was fur- 
nished in one of Middeldorpf's cases; the patient's right arm was 
caught in some machinery and he was whirled around, receiving in 
addition to the dislocation a wound of the deltoid ; he died of pyemia. 
The greater tuberosity had been torn off, remaining attached to its 
three muscles, and the acromion was broken. Scharm produced the 
dislocation five times upon the cadaver ; in every case the supraspina- 
tus and infraspinatus muscles were torn away, and in two there was 
partial rupture of the subscapularis and pectoralis major. The main 
bloodvessels and nerves were uninjured. My only knowledge of Mid- 3 
deldorpf's cases and Scharm's experiments comes from the brief men- 
tion made of them by Alberti. 

Lange's case, in which the dislocation was intracoracoid rather than 
subglenoid, differs also from the others in the less complete elevation 
of the arm. Bardenheuer l says that in his experience, covering about 
four hundred cases of dislocation of the shoulder, he had never encoun- 
tered a pure luxatio erecta, but he had met with two cases in which the 
arm was abducted beyond a right angle with the body. Lange's case 
might properly be regarded as an exceptional form of intracoracoid dis- 
location intermediate between the usual form and the luxatio erecta. 

The mechanism appears to have been forcible and extreme elevation 
of the arm, combined in one case (Alberti's) with a blow upon the 
arm from above downward, and the elevated position after dislocation 
was plainly due to the tension of the anterior soft parts created by the 
shifting of the centre of motion to a point so far below the glenoid 
cavity. In one of Meyer's cases mentioned by Bardenheuer, a woman 
sixty-two years old, it is said that the dislocation occurred during an 
epileptic fit. It is stated also that in one of the cases " paralysis of 
the brachial plexus" persisted after reduction. 

The method of reduction adopted in all the cases was clearly the 
proper one, not only because it succeeded but also because it corre- 
sponded to the anatomical indications. Traction in the direction 
assumed by the arm drew the head directly back toward its socket by 
the route along which it had escaped. 

3. Subtricipital Dislocation (?). 

Our knowledge of this very rare, and even questionable, form is 
limited to a single doubtful case observed clinically by Farabeuf, 2 and 
to subsequent experiments made by him upon the cadaver. As the 
luxatio erecta is produced from a subglenoid by exaggerating the 
descent of the head of the humerus, so the subtricipital is said to be 
produced from the erecta by a consecutive displacement of the head 
upward and backward, at first underneath and then behind and above 
the long tendon of the triceps, a displacement effected by the descent 
of the elbow in front. 

The case was that of a sailor who injured his shoulder while at sea ; 
five weeks later he landed at Bordeaux, and, attempts made there to 

1 Bardenheuer: Loc. cit., p. :5(>;>. 

2 Farabeuf: Bull, de la Soc. de Chirurgie, 1ST!), p. 778, and 1885, p. 3M. 



600 DISLOCATIONS. 

reduce having failed, he went to Paris. The arm was abducted and 
carried forward, and the head of the humerus rested on the back of 
the scapula two finger-breadths below the angle of the acromion. 
Reduction was not obtained. 

In his experiments upon the cadaver Farabeuf found that after rais- 
ing the arm forcibly and thus tearing the capsule at its lower part he 
could, by a vigorous push or a blow upon the elbow with a mallet, 
make the head of the humerus descend several centimetres below the 
glenoid cavity ; if then the arm was lowered in front the head of the 
•bone moved backward and became engaged under the tendon, which 
then held the arm abducted and directed forward and more or less 
rotated inward. 

Farabeuf 7 s case is apparently the one mentioned by Poinsot 1 as 
Sebilleau's and as having been examined by himself in 1881. The 
limb was then in slight abduction and inward rotation, the elbow and 
fingers flexed ; movements at the shoulder were almost completely 
lost. The case is described by Poinsot as 'one of dislocation backward 
(subacromial or subspinous), and no reference is made by him to 
Farabeuf 's opinion concerning it, although he is named among the 
surgeons who had examined it. 

Farabeuf maintains that two very similar cases observed by Richet 
and Bottey and named by the former retro-axillary (see Posterior Dis- 
locations) were really examples of this variety described by him. It 
seems more probable that Farabeuf was misled by his experiments 
and that the three cases were merely low posterior dislocations. 

Supposing such a case to exist, reduction should be made by first 
transforming the dislocation into a luxatio erecta by raising the elbow 
with traction to the side of the head, so as to bring the bone from 
beneath the triceps, and then reducing by direct traction upward. 

POSTERIOR DISLOCATIONS. 
Subacromial and Subspinous. 

Dislocations backward are divided into two classes, the subacromial 
and the subspinous, according as the head lies under the projecting 
outer border of the acromion or further back below the spine of the 
scapula, respectively. A variety of the subacromial, to which the 
name retro-axillary has been given, has been recently observed and 
described by Pichet and Bottey. 

Although I think this division into two groups is quite generally 
accepted by the profession, yet English and American systematic 
writers upon the subject have, as a rule, refused to adopt it, giving as 
a reason therefor the fact that the two differ only in an unimportant 
feature, the degree of the displacement, and they apply the term sub- 
spinous to all. Flower 2 justifies the choice of this name in preference 
to subacromial on the ground that the latter does not express any 
change from the normal situation of the head of the humerus under 
the acromion. On the other hand, it may be fairly urged that, as in 

1 Poinsot : Translation of Hamilton's Fractures and Dislocations, p. 867. 
3 Flower: Holmes's System of Surgery, Am. ed., vol. i. p. 875. 



POSTERIOR DISLOCATIONS OF THE SHOULDER. 601 

the great majority of eases the head is not displaced so far as to the 
spine of the scapula, the term subspinous is misleading and improper. 
I have preferred, in accordance with what I believe to be the general 
practice of the profession, to retain both terms with the distinction 
between them established by Malgaigne. Of the two groups the sub- 
acromial is much the more frequent, the subspinous being very rare. 

According to Malgaigne the earliest recorded mention of this dislo- 
cation was in 1834, and when he wrote, in 1855, he could collect only 
34 cases, of which he himself observed 3. A very considerable num- 
ber of cases have been recorded since that time (I found 7 in the Index 
Iledicus for the years 1878 to 1882), and Pana's opinion that many 
escape recognition, by being mistaken for a sprain or an articular frac- 
ture, seems fairly justified, for not only are the diagnostic symptoms 
sometimes very obscure, but Nelaton said that he had within a short 
period of time seen three cases that had passed unrecognized by sur- 
geons of merit. Ellerbrook * reports seven traumatic cases among 172 
dislocations of the shoulder treated in the Gottingen Poliklinik. In 
Malgaigne' s statistics 26 were men and 5 women ; and in rather more 
than a quarter of them the cause was muscular action. Bardenheuer saw 
one in which both shoulders had been dislocated by a fall forward upon 
the elbows. (See, also, Chapter XLIV., Congenital Dislocations.) 

Experiment upon the cadaver shows that the dislocation can be 
readily produced by forcible internal rotation of the arm, by which 
the posterior portion of the capsule is torn and the passage backward 
and outward of the head is made easy. In some of the cases clinically 
observed it is plain that this has been the mechanism, and in others 
it has undoubtedly aided. Thus, Piel, who wrote a thesis on the sub- 
ject in 1851, saw a woman in whom it had been caused by her husband 
twisting her arm in a quarrel. In seven of Malgaigne's cases and in 
several that have since been reported the dislocation occurred during 
an epileptic fit, presumably by internal rotation of the limb. In other 
cases the cause has been a blow upon the front of the shoulder (twice 
a blow with the fist), pressure upon the back of the shoulder while the 
elbow rested against the ground, an attempt to control the patient in 
convulsions, once the throwing of a stone by a boy ten years old, and 
frequently a fall. The anatomical features of the joint, the results of 
cadaveric experiment, and such histories of cases as are sufficiently 
complete indicate that the common mode of production is pressure 
backward and outward upon the head of the humerus, either directly 
or through the elbow, combined with adduction of the limb across the 
front of the chest and internal rotation. Such a combination is most 
frequently found in falls forward in which the weight is received upon 
the adducted elbow. One of Malgaigne's cases is especially interesting 
from this point of view, as showing the conditions of the production 
almost as clearly as an experiment. A woman was trying to take 
down a box placed high above her head, it slipped suddenly into her 
extended hand, and the dislocation occurred. In other words, the force 
was exerted in a suitable direction upon an arm that was elevated, 
adducted, and rotated inward. 

i Ellerbrook : Deutsche Ztschffc. fiirChir., vol. xeii, p. 453. 



602 DISLOCATIONS. 

In a case observed by Tillaux 1 the patient, a man twenty-four years 
old, had his right arm caught in some machinery and was drawn sev- 
eral times about a revolving shaft, receiving a subspinous dislocation, 
and in addition having the arm almost completely torn away at its 
middle by being twisted several times upon itself. 

Autopsies have been made in six recent cases in which death was 
caused by associated injuries. In Maisonneuve's case (the specimen 
is pictured in Malgaigne's Atlas, Plate XXII., figs. 5 and 6) the 
patient fell from a height of thirty feet. The capsule was torn above, 
below, and on its outer side ; the greater tuberosity was torn off, broken 
into two pieces, and drawn back below the acromio-clavicular arch by 
the supraspinatus and infraspinatus muscles to which it remained 
attached. The teres minor and subscapularis were still attached to the 
humerus ; the long tendon of the biceps had been torn out of its groove. 
The circumflex nerve was uninjured. The head of the humerus lay 
just below the posterior angle of the acromion and was not in contact 
with either the spine or the neck of the scapula, but rested against the 
posterior edge of the glenoid cavity. 

In Laugier's 2 case the subscapularis and supraspinatus were torn 
from their insertions, and the head of the humerus had passed, as in 
Maisonneuve's case also, between the infraspinatus and teres minor 
and was covered only by the deltoid. 

Two cases were reported by Jossel, 3 one a subacromial, the other a 
subspinous dislocation. In the first the injury, together with a frac- 
ture of the skull, was caused by a fall into a cellar. The head of the 
humerus had torn through the teres minor and lay under the acromion ; 
the limb was so far rotated inward that the articular surface looked 
directly outward. The supraspinatus and infraspinatus were unin- 
jured. The capsule showed a triangular rent on the outer side just 
large enough to let the head through. The tendon of the subscapu- 
laris was still attached to the humerus, but under it and close by the 
tendon of the biceps an irregular, movable piece of bone could be felt, 
the lesser tuberosity, the fracture by which it was separated extending 
into the bicipital groove ; the tubercle was split into two pieces, both 
adherent to the tendon. 

In the second case the patient fell from a height of two stories, 
dislocated the left shoulder, and sustained a compound fracture of 
the thigh ; he died on the fifth day. The head of the humerus had 
torn through the teres minor and lay under the spine of the scap- 
ula, separated from it by the interposed infraspinatus ; it was directed 
backward. The long head of the triceps was almost entirely torn 
through, and a piece was broken from the axillary border of the scap- 
ula just below the glenoid fossa. The subscapularis and the adjoining 
part of the capsule were torn away from the humerus, bringing with 
them the lesser tuberosity, the fracture of which was broader than in 
the preceding case. 

In the remaining two cases the dislocations were subspinous ; in one 

1 Tillaux: Anatomie topograph ique, p. 536. 

2 Laugier: Gaz. des Hopitaux, 1846, p. 60. 

3 Jossel : Deutsche Zeitschrift far Chir., 1874, vol. iv. p. 125. 



POSTERIOR DISLOCATIONS OF THE SHOULDER 603 

of them, quoted by Malgaigne, 1 the patient, a man sixty-two years old, 
fell backward, and the wheel of his wagon, which carried a load of* 
three and a half tons, passed obliquely across the right side of his 
chest, causing injuries which resulted in his death thirty hours later. 
Several ribs were fractured, as were also the body of the scapula and 
the inner portion of its spine. The deltoid, pectoralis major, teres 
major, and teres minor were torn or crushed, and the capsule was 
almost entirely detached. When the arm was lowered the head of the 
humerus lay below the spine of the scapula in the outermost part of 
the subspinous fossa, the lesser tuberosity corresponding to the edge 
of the glenoid fossa. 

In the other, reported by Collins, 2 a man sixty years old was knocked 
down and run over, sustaining, in addition to the dislocation of his 
right shoulder, fracture of several ribs ; he died in a few days of pneu- 
monia. The capsule was torn on all sides ; the supraspinatus and 
subscapulars were torn away at their insertions, and the long tendon 
of the biceps was detached from the bicipital groove. The head of 
the humerus lay between the teres minor and the infraspinatus, 
" immediately beneath the scapular spine." 

In an operation for the reduction of old dislocation 3 the lesser 
tuberosity was found to have been broken off. 

The important complication of fracture of the anatomical neck has 
been reported in two cases, one by Delpech, the other by Malgaigne ; 4 
in each the cause was a fall upon the shoulder. In Delpech's case the 
fall was due to an apoplexy which soon proved fatal ; the head had 
passed entirely through a large rent in the postero-external part of the 
capsule, its fractured surface lay against the subspinous fossa, and its 
articular surface was directed backward and covered by the infraspi- 
natus muscle. The muscular attachments to the humerus were all 
preserved, and the long tendon of the biceps was intact. 

Malgaigne's case was not seen by him until eleven months after the 
receipt of the injury ; the head of the humerus could be felt as an 
immovable, hemispherical body, two inches in diameter, and half an 
inch below the posterior angle of the acromion. The arm was short- 
ened half an inch, the elbow slightly abducted and not rotated. The 
upper end of the shaft corresponded to the glenoid cavity. The arm 
was slightly movable ; the head did not share in its movements. 

The results obtained by experiments upon the cadaver are in har- 
mony with these post-mortem records. In the subacromial variety the 
head of the humerus is found under the acromion looking backward 
and inward, with its anatomical neck engaged against the posterior 
edge of the glenoid fossa, and the lesser tuberosity lying on the latter. 
The tendon of the subscapularis covers the anterior and inner part of the 
fossa, and is usually more or less detached from its insertion upon the 
humerus. The dislocation can be transformed into a subspinous one 

1 Malgaigne: Loc. cit., p. 541. According to Soyez (These de Paris. 1880, Xo. 179) the 
case was treated by Denonvilliers, who deposited the specimen in the Musee Dupuvtren. 
It is reported by Malgaigne as if he had himself observed it. Hence has arisen the error 
of supposing that they were different cases. 

2 Collins; Dublin Journal Med. Sci., 1879. vol. ii. p. 166. 
:1 Engel : Arch, fur klin. Chir., 1897, vol. lv. p. 603. 

4 Soyez : These de Paris, 1880, No. 179, p. 28. 



604 DISLOCATIONS. 

by diminishing the internal rotation sufficiently to free the lesser tuber- 
osity, and then forcing the humerus backward toward the dorsum of 
the scapula, tearing the capsule more extensively, lacerating the infra- 
spinatus, increasing the separation of the subscapularis, and tearing 
oif also the supraspinatus from its insertion. The dividing line 
between the two varieties is necessarily an arbitrary one, and in some 
cases it must be difficult to determine to which variety the case belongs. 
Malgaigne's definitions are as follows : The subacromial is one in which 
the head of the humerus lies under the posterior angle of the acromion ; 
the subspinous, one in which it has been displaced behind the angle of 
the acromion and lies under the spine of the scapula. 

Symptoms. The symptoms in recent cases are not very marked, and 
the characteristic ones may be masked by the swelling. In the sub- 
acromial variety the shoulder seems full behind and flattened in front. 
The arm hangs by the side, the elbow usually directed somewhat for- 
ward, and is rotated inward. The coracoid process can be plainly felt, 
and perhaps seen ; the acromion is prominent in front. The absence 
of the head of the humerus from its socket is recognized by pressure 
made in front, and its presence behind and to the outer side is deter- 
mined by palpation combined with gentle movements of the limb. In 
the older cases the subsidence of the inflammatory swelling and the 
atrophy of the deltoid consequent upon disuse make the deformity 
more marked. Voluntary movements are abolished, and communicated 
movements restricted and painful. Comparative measurements have 
not shown constant or notable differences in length. In two cases of 
my own the arm was rigidly held close to the side, and communicated 
movements were extremely painful. Reduction by traction, under 
ether, was easy, and full use of the limb was promptly regained. 

The attitude is probably due to the persistence of the anterior 
portion of the capsule, which is noted in most of the autopsies and 
all the experiments upon the cadaver. 

In the subspinous variety the attitude of the arm in the few reported 
cases has not been always the same ; sometimes the elbow has been 
held close to the trunk and projected forward ; in Malgaigne's it was 
rotated inward, but otherwise freely movable, and remained in such 
position as was given to it. In Desclaux's it was held horizontally in 
front of the upper part of the chest, and, as any attempt to lower it 
caused great pain, the patient sought to keep it immovable by placing 
the hand on the top of his head. The local symptoms at the shoulder 
are much the same as those in the subacromial variety ; there is the 
same prominence of the coracoid process and acromion, the flattening 
of the front and the fulness of the back of the shoulder, the absence 
of the head of the humerus from its socket and its presence behind, 
in this case, of course, further back behind the angle of the acromion 
and below the spine of the scapula. 

Riehet, in 1882, treated a case which differed widely in one respect 
from both the subacromial and subspinous forms, namely, in that the 
head of the humerus, instead of being in contact with the acromion, lay 
at a distance of two finger-breadths below it, close behind the glenoid 
fossa. He considered it a new variety, representing the first stage in 



POSTERIOR DISLOCATIONS OF THE SHOULDER. 605 

the production of the subacromial, and gave it the name of retro- 
axillary. The case was published by Bottey, his interne, in the Pro- 
f/res Medical, August 5, 1882, and subsequently republished with 
another also observed by Bottey in his graduating thesis. 1 The two 
cases resembled each other very closely ; the patients were women, aged 
seventy-eight and seventy-two years, respectively, and the injury was 
caused in each case by a fall upon the shoulder ; in one, while walking 
in the street; in the other, from her bed, against a chair. The elbow 
was directed forward and held near the body, and in the second case 
the patient supported the limb with the other hand because of the pain 
its weight caused. As both patients were thin and there was no swell- 
ing, the head of the humerus could be very distinctly felt behind the 
posterior edge of the glenoid fossa and slightly separated from it, and 
distant from the acromion by two good finger-breadths. External 
rotation of the limb was marked. Reduction was easily effected by 
direct impulsion, and both patients recovered promptly. 

The position of the head may be explained by assuming that the 
rent in the capsule was exceptionally low, and did not extend upward 
along the posterior border of the glenoid fossa. 

Prognosis. The prognosis is favorable as regards the probability of 
effecting reduction (in two or three cases the head has been unexpect- 
edly returned to its place by the manipulations employed to make the 
diagnosis), but it is very unfavorable if the dislocation is left unre- 
duced, for then the range of motion is usually very slight. In a case 
reported by Sir Astley Cooper, in which the dislocation immediately 
recurred after every reduction and was finally abandoned, the patient 
survived seven years, but remained unable to use or even move the 
arm to any extent. The tendency to recurrence was attributed to the 
separation of the tendon of the subscapularis from the humerus, and 
to the consequent lack of support on that side. The same tendency 
has been noted in other cases. Bardenheuer says it existed in three of 
his four, and that in two of them movements of the joint gave rise to 
crepitus. In some of the cases the full use of the limb has been 
regained in a very short time after reduction, a week or ten days. 

Diagnosis. The diagnosis, as has been already said, may be difficult, 
especially if there is much swelling. The injury appears to have been 
not infrequently mistaken for a sprain or a contusion. The attitude 
and the direction of the axis of the arm, except in the rare subspinous 
cases, are not sufficiently characteristic even to suggest the existence of 
the injury, and unless the examination is systematically made with a 
view to determine the position of the head of the humerus, as should 
be done in all cases of injury in this region, the dislocation may be 
overlooked. If the head of the bone can be felt and its relations to 
the acromion determined, no doubt should remain. 

Treatment. Reduction has been easily effected in both recent and 
old cases by a variety of methods. The one that has furnished the 
largest number of successes is direct pressure from behind forward 
upon the head of the humerus with counter-pressure upon the front of 

1 Bottey: Deux cas rie luxation do l'epaule enarriere et eu bus (luxation retro-axillaire . 
These de Paris, 1884, No. 13. 



606 DISLOCA TIOXS. 

the acromion, usually associated with traction upon the arm, or with 
gentle movements of the limb in various directions. Sedillot success- 
fully reduced a dislocation that had existed for a year and fifteen days. 

The position and relations of the untorn portion of the capsule indi- 
cate that the best manipulation would be elevation of the elbow in 
front and toward the median line, combined with inward rotation to 
relax the anterior portion of the capsule, and followed by direct pro- 
pulsion of the head from behind toward its socket, or by traction in 
the direction of the long axis of the arm. Simple external rotation 
might succeed when the articular surface of the head rests against the 
edge of the glenoid cavity, as it sometimes does, for by making the 
front of the capsule tense it would rotate the posterior surface of the 
bone inward and forward, but the success of this manipulation might 
easily be prevented by the increased friction between the two bones. 

In a case of subspinous dislocation reported by Dr. J. E. Michael l 
reduction made on the fifty-ninth day remained incomplete. The 
patient was a boy sixteen years old, who had received the injury by a 
fall from a horse ; the head of the humerus lay at the junction of the 
middle and outer thirds of the spine of the scapula, the arm was slightly 
rotated inward, and the hand could be raised only to the nipple. After 
trying elevation and rotation without success, the head was brought by 
traction so nearly into place that the hand could be placed upon the 
opposite shoulder, but the form of the shoulder remained imperfect 
because of the undue prominence of the head of the humerus behind 
and on the outer side. Six months later the deformity persisted and 
there was considerable emaciation of the region ; there was slight 
mobility, rotation was entirely lost, and the hand could be brought to 
the head only with an effort. 

UPWARD DISLOCATIONS. 

Supraglenoid, Supracoracoid. 

The possibility of the occurrence of this rare form of dislocation, 
which has often been denied, has at last been established by the clin- 
ical observation of several cases and the post-mortem examination of 
two. 

The first alleged case was reported by Laugier 2 in 1834 as an incom- 
plete dislocation upward; the second was by Malgaigne. 3 In 1858 
Bourget submitted to the Societe de Chirurgie a paper upon the subject 
containing the accounts of three cases observed by himself, two of 
which he diagnosticated as complete dislocations, and one as incomplete, 
and reproducing the cases of Laugier, Malgaigne, and Avrard. Upon 
this paper Morel-La vallee 4 made an elaborate report, denying the cor- 
rectness of the diagnosis in all the reported cases and attributing the 
observed deformity to a prolonged arthritis, and he supported this 

1 Michael : The Medical News, 1884, p. 621. 

2 Laugier: Arch. gen. de Med., 1834, vol. x. p. 65; also in Dictionnaire en 30 vols., vol 
xiii. p. 81. 

3 Malgaigne : Rev. rnedico-chirurg., 1849, vol. v. p. 30, and Luxations, p. 530. 
* Morel-Lavallee : Bull, de la Soc. de Chir., 1858, vol. viii. p. 490. 



UPWARD DISLOCATIONS OF THE SHOULDER. 607 

opinion by quoting the case of Soden, 1 in which the symptoms were 
the same as in Laugier's case, but the autopsy, five months later, 
showed the changes of a dry arthritis. He seems to have attached no 
importance to the dislocation inward of the long tendon of the biceps. 
The alleged cases on record are Malgaigne's, two of Bourget, and 
those of Chassaignac, 2 Holmes, 3 Prescott Hewett (quoted by Holmes), 
Denonvilliers, 4 Albert, 5 Busch,' 5 Verneuil, 7 Le Dentu, Tuffier, 8 Rob- 
son, 9 and Streeter, 10 fourteen in all, in one of which (Albert) both 
shoulders were dislocated in the same manner and at the same time. 

The cases that furnished autopsies are Holmes's, Albert's, and Tuf- 
fier's. Holmes's patient was a man fifty years old, who had fallen 
from a height of about thirty feet, striking upon his head, the left side 
of his chest, and left elbow, and receiving in addition to the dislocation 
in question a compound dislocation of the radius and a comminuted 
fracture of the upper portion of the ulna of the same side. The head 
of the humerus formed a large prominence in front of the outer part 
of the clavicle ; movements of the arm gave rise to crepitus. No 
attempt to reduce was made, and the patient died on the fifteenth day. 

At the autopsy the head of the humerus was found immediately 
under the skin, having passed through the deltoid near its inner ante- 
rior margin ; its articular surface was entirely above the glenoid fossa 
and rested upon the stump left by fracture of the coracoid process 
near its base. The coracoid process lay on its inner, the acromion on 
its outer side and somewhat posteriorly ; the coraco-acromial ligament 
appears to have been in part torn. The subscapularis was intact, but 
the muscles attached to the greater tuberosity were torn through, 
except a part of the teres minor. The long tendon of the biceps lay 
below the head on its outer side ; it was still attached to the upper 
margin of the glenoid fossa, but some of its inner fibres had been 
broken away from the muscle. The capsule was torn at its upper and 
inner part. 

Albert's case was first seen by him several years after the injury was 
received. The patient had dislocated both shoulders by holding on to 
the reins of a pair of runaway horses and being drawn along the 
ground. The deformity was more marked on the left than on the 
right side, and there consisted of a marked rounded prominence on 
the front and upper part of the shoulder. Both arms hung close by 
the side, the axis being directed obliquely from below upward and for- 
ward in front of the glenoid fossa. The prominence formed by the 
head of the humerus was situated in front of the acromion, rising 
about two centimetres above its upper surface, and this elevation could 
be increased by pressing the elbow upward ; the arms were so far rotated 

1 Soden: Medico-Chirurgical Transactions, vol. xxiv. p. 212. 

2 Chassaignac: Bull, de la Soc. de Chir., 1858, vol. viii. p. 472. 

3 Holmes: Medieo-Chirurgical Transactions, 1858, vol. xli. p. 447. 

4 Denonvilliers, in Panas: Diet, de Med. et Chir. pratiques, art. Epaule, p. 469. 

5 Alhert: Chirurgie, 2d ed., 1881, vol. ii. p. 287; also in Wiener med. Blatter. 1879. 
p. 453. 

fi Busch: Arch, fur klin. Chir., 1870, vol. xix. p. 400. 

7 Verneuil in Pellier : These de Paris, 1878. 

8 Turner : Bull, de la Soc. Anat.. 1886, p. 292. 

9 Robson : Annals of Surgery, 1888, p. 175. 

10 Streeter : Medical Record. February 26, L887. 




608 DISLOCATIONS. 

outward that the transverse diameter of the lower end of the humerus 
coincided with the transverse axis of the trunk. The outer deltoid 
region was not noticeably flattened, but posteriorly the fibres of that 
muscle were greatly relaxed and the posterior edge of the glenoid fossa 
could be distinctly felt through them. The point 
Fig. 302. f the finger could be pressed in between the head 

and the coracoid process. Slight voluntary rotation 
and movement of the elbow forward and backward 
were possible ; very slight passive abduction. The left 
elbow could be flexed only to a right angle, further 
flexion being arrested by the triceps. On the right 
side the deformity was the same in character, but 
less in degree, and there was the same limitation of 
motion. If pressure was made upon the elbow di- 
rectly upward the movement could be distinctly felt 
to be arrested by bony contact, and this demonstrably 
occurred between the head of the humerus and the 
clavicle, but if the elbow was first carried back- 
ward the head could then be pushed up higher. 
At the autopsy the capsule was found attached 
^r^TitBERT) throughout to the anatomical neck of the humerus 
and adherent also to the upper part of its articular 
surface ; thence it extended without interruption to the margin of 
the glenoid fossa, but its cavity was considerably enlarged. The 
coraco-acromial and coraco-clavicular ligaments were uninjured. The 
upper third of the head of the humerus lay above the level of the 
coraco-acromial ligament, and this overlapping could easily be in- 
creased to half the head. The glenoid fossa was filled with a thick 
layer of fibrous tissue. 

In the fuller account given in the Wiener medicinische Blatter, 1879, 
p. 453, quoted by Poinsot, it is said that the long tendon of the biceps 
on the left side was ruptured and its end adherent to the bone in the 
bicipital groove, and that an osteophyte an inch long had grown. from 
the base of the coracoid process. 

Tuffier's specimen was found in the dissecting-room. The acromion 
was broken off near its base and turned up and out ; the head of the 
humerus was in direct contact with the acromion and coracoid, and 
the joint showed old changes of dry arthritis, including ossification of 
the long head of the triceps. 

To these may be added Robson's observations made during an arth- 
rotomy. His patient was a boy sixteen years old who had received 
his injury six weeks earlier by the forcible dragging of his right arm 
upward and backward. The description of the symptoms is not very 
clear, but the head of the humerus " lay about a finger-breadth in 
front of the right acromion and immediately to the outer side of the 
coracoid process." Motion of the arm was limited in every direction 
except backward. The bone was exposed by a curved incision on the 
outer side of the shoulder, and "it was then discovered that in addi- 
tion to the dislocation of the head of the humerus there was a longi- 
tudinal fracture separating the greater tuberosity from the head and 



UPWARD DISLOCATIONS OF THE SHOULD EH. 



609 



extending down the shaft for some distance beyond the line of incision. 
. . . Reduction could not be effected in consequence of the glenoid 
fossa being filled with callus and plastic material thrown out around 
the fracture." 

The other cases are as follows : 

Malgaigne. A man sixty years old was thrown from a wagon, 
striking upon his shoulder while his arm was held close to his side. 
There was much pain and he was unable to move the limb. A " bone- 
setter " handled him roughly and sent him away with his arm in a 
sling. Two and a half months later he consulted Malgaigne. The 
head of the humerus was dislocated upward and forward above the 
coracoid process, reaching the under surface of the clavicle, and stretch- 
ing the overlying deltoid so that on perforation with a pin the latter 
proved to be only eight millimetres in thickness ; shortening one-fifth 
of an inch. Traction to the extent of more than four hundred pounds, 
combined with pressure upon the head downward, outward, and back- 
ward and counter-pressure on the acromion, failed to effect reduction, 
although it made the head so movable that it could be drawn down a 
finger-breadth below the clavicle. Malgaigne meditated division of 
the coraco-acromial ligament, which seemed to be the obstacle, but 
refrained. 

Bourget's cases resembled Malgaigne's closely. 

Busch. (Fig. 303.) A horse reared and struck the patient, who 
was holding him by the bridle, upon the inner and anterior part of 
the shoulder with his hoof. The head of the humerus was displaced 
upward and forward, the deformity closely 
resembling that in Malgaigne's case ; the 
infraclavicular fossa was deepened, the arm 
hung close by the side, the posterior deltoid 
region was hollowed, the coracoid process 
could not be felt in its place. Reduction 
failed. 

Denonvilliers. A man fell upon his arm, 
but was unable to give the details of the 
fall. The limb hung by the side and was 
strongly rotated outward. Ecchymosis, pain, 
loss of function. The head of the humerus 
projected forward and upward between the 
coracoid and the acromion and in front of 
the clavicle. Oblique traction, combined 
with a slight movement of leverage, effected 
reduction. 

Chassaignac. A man fell from the third 
story of a building. The head of the hu- 
merus projected directly outward and ex- 
tended above the coraco-acromial ligament. 
Movements of the elbow forward were impossible, backward they wore 
more free than normal. The dislocation was easily reduced by exag- 
gerated elevation of the arm, but recurred when the arm was lowered, 

Hewett. The patient was a middle-aged woman ; the head oi^ the 



Fig. 303. 




>upraj 



enoid dislocation : Busch's 
se. (Bardenheuer.) 



610 DISLOCATIONS. 

humerus lay on the upper and inner side of the glenoid cavity ; there 
was distinct crepitus which ceased after reduction had been made by 
traction with the heel in the axilla. Apparently the patient made a 
complete recovery. 

Streeter. "A man of middle age fell down stairs, striking on his 
elbow. The coracoid process was evidently fractured, and the articular 
head of the humerus was plainly felt above the clavicle, the patient 
being very thin. At the present time he is making good progress 
toward recovery." 

Fracture of the coracoid progress existed in Holmes's and Streeter's 
cases, and possibly also in Hewett's and Busch's. 

Rupture or displacement of the long tendon of the biceps must 
occur, and rupture of the muscles attached to the greater tuberosity 
is noted by Holmes ; it seems not unlikely that the impossibility of 
reduction in several of the cases was due to the interposition of the 
tendon of the biceps or the stump of the supraspinal s. 

The mode of production cannot be determined with an approach to 
precision except in the cases of Holmes and Streeter, in both of which 
the arm was driven upward by a blow upon the elbow. Tuffier's frac- 
ture of the acromion suggests a similar cause. 

Panas's experiments upon the cadaver show that if the arm is stronglv 
rotated outward while held close to the body, and then pressed bodily 
upward and forward, the capsule will tear at its upper part and the 
dislocation will be produced without fracture of the coracoid process, 
the head of the humerus rising not more than one centimetre above its 
normal position. 

The symptoms consist in the presence of the head of the humerus 
in the interval between the coracoid process and the acromion above 
its proper level. The coracoid process can be felt with difficulty, 
if at all. Usually voluntary movements are almost or quite impos- 
sible, and passive movements greatly restricted, and this restriction 
exists in old as well as in recent cases. 

In three cases seen while the injury was recent, Denonvilliers, Chas- 
saignac, and Hewett, reduction was easily effected by traction in two 
and by elevation of the elbow in one, but the dislocation recurred in 
the latter ; Verneuil reduced on the thirty-sixth day by traction aided 
by anaesthesia. In Holmes's case the associated injuries were so severe 
that reduction, for which the aid of chloroform was thought to be 
necessary, was not attempted. Malgaigne, Bourget, and Busch failed, 
the duration of the dislocation at the time of the attempt being two 
and a half, six, and five months respectively. The details of Bourget's 
second case are not given, and the result in Le Dentu's I do not know. 
In Albert's the dislocation had existed for many years, and no mention 
is made of any attempt to reduce. In Streeter's reduction seems to 
have been made. The persistent displacement in Tuffier's cannot be 
accounted for except by supposing that the arm was too well supported 
in a sling while the injury was recent. 



CHAPTER XLIV. 

DISLOCATIONS OF THE SHOULDER.— (Continued.) 

Associated Injuries and Complications — Prognosis — Habitual Dislocations — Old 
Dislocations — Congenital and Pathological Dislocations. 

Associated Injuries and Complications. 

The complications which may coexist with a dislocation have been 
described in Chapter XXIX., and will therefore be treated but briefly 
here, and mainly with the view of adding some details to the account 
already given. In like manner the accidents which may be caused by 
attempts to reduce a dislocation have been described in Chapter 
XXXIV. 

The injuries which are more or less frequently associated with dis- 
locations of the shoulder, but which are without such special bearing 
upon the prognosis or treatment as would make them actual complica- 
tions, have been mentioned in connection with the different forms of 
dislocation in the preceding chapters. The most important are the 
lacerations of the different muscles and tendons or their equivalent 
avulsion from the humerus with more or less of the tuberosities to 
which they are attached. 

Laceration of the subscapularis is frequent, and avulsion of the 
lesser tuberosity to which it is attached is very rarely substituted for 
it, apparently only in some of the backward dislocations. The extent 
of the laceration of the muscle can only be inferred from the extent 
and direction of the displacement, and it is believed to be without 
important influence upon the completeness of the repair and the subse- 
quent security of the joint. The position of adduction and inward 
rotation in which the limb is habitually kept during the period of con- 
valescence favors the repair of the muscle, and since the rupture is 
usually incomplete the torn portions do not widely retract. 

With the muscles attached to the greater tuberosity it is somewhat 
different. The muscles themselves are rarely torn, but the upper and 
middle facets of the greater tuberosity to which the supraspinatus and 
infraspinatus muscles are attached are frequently broken off and more 
or less retracted under the acromion, or the tendons are torn away from 
them and retracted. The importance of this associated injury, through 
its effect upon the subsequent usefulness and security of the joint, may 
be great; not only may the power of voluntary external rotation be 
diminished thereby, but the consequent loss of support on the outer 
side of the joint favors recurrence of anterior dislocation, and the great 
lengthening of the upper portion of the capsule and the enlargement 
of its cavity which are effected by the retraction of the supraspinatus 
and the establishment of free communication between the joint and the 



612 DISLOCATIONS. 

subacromial bursa make the joint much less secure, and this condition 
is thought to be the cause of the marked tendency to recurrence 
observed after some anterior dislocations (see Chapter XXIX.). Sim- 
ilarly the avulsion or rupture of the subscapulars in backward dislo- 
cations is responsible for the tendency to recurrence that has been so 
frequently noted in them. 

The tendon of the long head of the biceps appears habitually to escape 
rupture ; its sheath may be opened by the avulsion of either tuberosity, 
and then it may slip over the corresponding portion of the head, and, 
becoming engaged between the latter and the glenoid cavity, thus con- 
stitute a serious obstacle to reduction. When ruptured, its end is 
retracted into its sheath in the bicipital groove and there becomes 
united with the bone. 

Fracture of the greater tuberosity appears to be not often capable 
of demonstration ; at least it has often been found post mortem when 
it had not been recognized during life, although the proper explanation 
of the failure to recognize it may be that it was not sought for. If 
the fragment is retained in contact with the humerus by the untorn 
periosteum, crepitus may perhaps be obtained by manipulation ; and 
when the fragment is widely withdrawn it may perhaps be felt under 
the acromion, or its absence may be recognized by the change in the 
shape of the corresponding part of the humerus, or the fracture may 
be indicated by exceptional symptoms accompanying the dislocation, 
such as greater mobility of the limb or the absence of fixed abduction 
of the elbow, or local pain on pressure. (See page 229.) 

Fracture of the lesser tuberosity is much less frequent. To the five 
cases mentioned in the chapter on fractures of tuberosities of the 
humerus (p. 232) may be added the two reported by Jossel and quoted 
in the preceding chapter in the section on posterior dislocations 
(p. 602). 

Fracture of the Anatomical or Surgical Neck. This serious complica- 
tion of the humerus is fortunately rare ; McBurney x was able to collect 
only 117 reported cases, although his search was aided by those of 
Oger 2 and Porrier and Mauclaire. 3 Buchanan, 4 reporting a personal 
case, gives a large and interesting collection of reported specimens and 
cases of fracture of the anatomical neck. See also article by Mason in 
the same number of the Annals of Surgery, in which he gives 63 cases 
subsequent to McBurney's collection. 

It is believed that the fracture follows the dislocation, but it is pos- 
sible that they may be coincident in fracture of the surgical neck when 
the dislocation is caused by violence acting on the outer aspect of the 
shoulder. Fracture of the anatomical neck is difficult of explana- 
tion. The probable cause, in my opinion, is the wedge-like action of 
the inner edge of the glenoid fossa against the anatomical neck (see 
page 579). I have seen it in one case of dislocation in an epileptic con- 
vulsion, during which, it was said, the patient's wrists were firmly 

1 McBurney . Annals of Surgery, April, 1894, and May 1896, 

2 Oger : Luxations scapulo-humerales compliquees de fracture. These de Paris, 1884. 
No. 361. 

3 Porrier and Mauclaire: Rev. de Chir., October, 1892. 

4 Buchanan : Annals of Surg. 1908, vol. xlviii., 659. 



DISLOCATIONS OF THE SHOULDER. 613 

held at his side by an attendant. Buchanan's suggestion that this 
action is made effective by forcible lowering of the abducted elbow 
after dislocation seems plausible. 

The fracture may occupy the anatomical or the surgical neck, or may 
extend through the tuberosities, or may be extensively comminuted. 
Of 68 cases collected by Thamhayn 1 the fracture in 14 was of the 
anatomical neck ; in 2 of these reduction was effected. The displace- 
ment in the great majority of cases is forward and inward, the head 
lying under or on the inner side of the coracoid process ; in a few cases 
it has been backward under the acromion. The upper fragment may, 
in addition, undergo rotation that will widely separate its broken sur- 
face from that of the shaft. Cases of the rare form in which the head, 
after fracture of the anatomical neck, has undergone complete reversal 
while remaining within the cavity of the joint have been quoted in 
Chapters XIX. and XXIX. The upper end of the lower fragment 
is usually drawn upward toward the glenoid fossa, overlapping the 
upper fragment on the outer side, and it may unite in this position by 
fibrous or bony union with the other fragment, or with the scapula. 

The upper fragment usually preserves its vitality and establishes new 
vascular connections ; in rare instances it has become necrotic and has 
been eliminated after prolonged suppuration. 

The diagnosis appears, in some cases, to have presented serious 
difficulties, because the fracture removed some of the most character- 
istic symptoms of the dislocation, such as the fixation and attitude 
of the limb, and the indication of the position of the head of the 
bone that is furnished by the direction of its long axis. In general 
terms, it may be said that when the dislocation of the head has been 
recognized the coexistence of a fracture may be suggested by the 
mobility of the limb, its shortening, and the greater extent of the 
ecchymosis, and proved by the independent mobility of the shaft and 
head with crepitus. When the signs of fracture are apparent the coex- 
istence of a dislocation can only be recognized by determining the 
absence of the head from its socket, and this may be made very diffi- 
cult by the swelling of the soft parts. It must be remembered that 
the same exceptional mobility may be given to the limb by extensive 
laceration of the capsule without fracture. The two positive signs, 
which the surgeon should spare no pains to recognize, are the absence 
of the head of the humerus from its socket, which proves the disloca- 
tion, and its failure to share in movements communicated to the shaft, 
which proves the fracture. 

The treatment presents grave difficulties because the existence of 
the fracture deprives the surgeon of that control over the move- 
ments of the head of the bone which, in a simple dislocation, can be 
exerted through its shaft. Reduction in a recent case may some- 
times (36 out of 80 cases, Oger) be effected by direct impulsion of the 
head back into place. This should always be attempted, with the aid 
of anaesthesia and gentle traction upon the abducted shaft in order to 
utilize such periosteal connection between the fragments as may remain. 

5 Thamhayn: Schmidt's Jahrbueher, 1861, vol. exl. p. 194. 



614 DISLOCATIONS. 

In two cases of fracture of the anatomical neck I made reduction in 
this manner very easily, holding the limb in full abduction and press- 
ing directly upon the head with the fingers deeply placed in the axilla. 
This failing, the alternative plans were to seek consolidation of the 
fracture and then to reduce the dislocation, or to prevent union of the 
fracture and thus obtain a false joint at its seat (Riberi), or to excise 
the fragment. Xine reported cases of the first plan gave seven failures 
and two successes, and even in one of the latter reduction was made in 




McBurney's hook for making traction upon the dislocated upper fragment. 

the third week. Seven cases of the second plan have been reported, 
but it is not easy to determine from the reports the measure of the 
functional success. In cases in which the displacement was unrelieved 
the usefulness of the arm was even more impaired than when an 
uncomplicated dislocation was left unreduced, because of the additional 
adhesions created by the fracture, and a large proportion of the patients 
appear to have suffered from the pressure effects of the dislocated head. 
The complication, therefore, remained a serious reproach to surgery, 
the only means of relief being excision of the head. 

In this juncture Dr. McBurney devised and successfully used a 
method of reduction which seems perfect in its efficiency and which, 
at least when the fracture is through the surgical neck, involves less 
risk than primary excision of the fragment. He makes an incision on 
the outer anterior aspect down to the upper fragment, drills a hole in 
the latter, inserts the end of a stout hook bent at a right angle (Fig. 
304), and with its aid makes the needed traction and rotation. After 
reduction has been thus made, he sutures the fragments together with 
catgut, and then treats the limb as for fracture. He has used the method 
in four cases, two each of the surgical and anatomical necks, all the 
wounds healing primarily, and with a functional result as good as that 
following an uncomplicated dislocation or fracture. 

In two cases in which I employed it the head was so completely 
separated from all attachments that it seemed best to remove it, and in 
another, five weeks after the accident, I made no attempt to preserve 
the head, believing that its removal would give a better functional 
result in view of the advanced age of the patient, his epileptic status, 
and the splintering of the tuberosity. 

Schlange l has recently reduced in two cases — one a fracture of the 
anatomical, the other of the surgical neck — by incising through the 

1 Schlange : Arch, fur klin. Chir., vol. 81, Part 2, p. 9. 



DISLOCATIONS OF THE SHOULDER. 615 

axilla, drawing the eoraco-brachialis forward ana the vessels and 
nerves backward, and making direct reposition. Mason (above quoted) 
reduced through an anterior incision, after fracture of the surgical neck, 
prying the head into position with an elevator. His paper contains 
full late statistics and a discussion of the methods of treatment. 

For statistics of various methods of treatment after failure to reduce, 
see Souchon, Transactions of the American Surgical Association, 1897, 
p. 322 ; B. F. Curtis, Annals of Surgery, March, 1900, p. 291 ; and 
Schoch, Beitrdge zur klin. Chir., 1901, vol. xxix. p. 103. 

Fracture of the shaft associated with dislocation of the shoulder has 
also been observed several times. It is a less serious complication than 
fracture of either the anatomical or the surgical neck, because the 
greater length of the upper fragment makes it easier to effect reduction. 

Fracture of the coracoid process has been observed in connection 
with dislocation of the humerus, not only in the case of supracoracoid 
dislocation mentioned above, but also in dislocation forward. 

Fracture of the acromion has also been occasionally observed. 
Kronlein's and my cases in which a blow received upon the top of the 
shoulder first broke the acromion and then dislocated the humerus into 
the axilla have already been mentioned (p. 574) ; also Tuffier's, in an 
upward dislocation. 

Fracture of the Glenoid Fossa. Probably the chipping of the edge 
of the glenoid fossa is not infrequent in dislocation, and passes un- 
recognized because of the lack of symptoms. Fracture of a large por- 
tion has been occasionally observed, both clinically and after death, 
and is of great importance in favoring recurrence of the dislocation. 
Malgaigne represents in his Atlas (Plate XXII., fig. 4) a case in which 
the anterior third of the fossa was broken off and had been displaced 
backward and become united with the neck of the scapula ; the symp- 
toms in the case were that the shoulder was less full and rounded 
than normal, and that the head of the humerus, while still in relation 
with the anterior part of the acromion, projected a few lines in front 
of the inner border of the coracoid process. 

The special indication for treatment is to prevent recurrence of the 
dislocation by fixation of the limb and pressure upon the head from 
the side on which the fracture has taken place. 

Nerves. Injury to the nerves, except of a slight and transitory 
character, is rare, and in most of the cases reported as such the injury 
has been inflicted during reduction. In two cases in which the injury 
was demonstrated by post-mortem examination, Hilton's 1 and Parise's, 2 
there was only a partial laceration of the circumflex nerve in the 
former, and in the latter rupture at different levels of the fibres com- 
posing it, only recognizable on minute dissection ; the nerve trunk 
was extensively infiltrated with blood; the dislocation was subglenoid, 
and the nerve was tightly stretched around the head of the humerus. 
In BourguesV (subglenoid) the main nerves were so compressed 

i Hilton : Guy's Hospital Reports, 1847, vol. v. p. 93. 
2 Parise : Gaz. Medicale de Paris, 1863, p. 210. 
:i Bourgues: Bull, de la Soc. Anat., 1888, p. 581. 



616 DISLOCATIONS. 

between the surgical neck and the fascia that they showed multiple 
grooves and punctate hemorrhages. In Midler's (p. -±-±1) the nerves 
and artery were compressed by a cicatricial band. 

It is occasionally found in unreduced dislocations that the sensibility 
of the skin over most of the deltoid region, which is supplied by the 
circumflex nerve, is diminished or lost, and that in others after reduc- 
tion the deltoid is paralyzed. This paralysis of the deltoid is thought 
frequently to be the result of direct bruising of the muscle by the 
violence that caused the dislocation, but that explanation does not sat- 
isfactorily account also for the loss of sensibility in the skin, and we 
must, in such cases, assume that the trunk of the circumflex has been 
stretched in the dislocation. 

In many of the reported cases it cannot be determined whether the 
injury to the nerve was caused by the dislocation or by the manoeuvres 
made to effect reduction ; in some it is clearly due to the dislocation. 
Illustrative examples have been quoted in Chapter XXIX. 

The cause of the paralysis, when it involves more than the circum- 
flex nerve, is very obscure. It has been attributed to compression of 
the main trunks in the axilla, but this explanation is not satisfactorily 
supported by post-mortem examination or experiment, and the fact 
that similar symptoms may follow blows that neither produce a dislo- 
cation nor directly involve the nerves adds to the difficulty. Xelaton 
sought to explain it by supposing a compression of the nerves between 
the clavicle and the first rib, and some cases have been reported which 
indicate that this explanation may, sometimes at least, be the correct 
one. Perhaps elongation, stretching of the brachial plexus in marked 
descent of the head may be a cause. Cf. Fisk's case, p. 204, and 
Flanbert's, p. 472. On the other hand, the prompt disappearance 
of the symptoms in some cases after reduction clearly points to 
pressure by the head or neck of the humerus upon the nerves as the 
cause. 

The paralysis may appear immediately or may develop gradually 
during the first two or three days, and it may be complete or partial. 
In some cases (see Chapter XXIX.) it has been followed by serious 
changes in the appearance and nutrition of the limb, presumably the 
effect of an ascending neuritis. In one case Bardenheuer 1 demon- 
strated the existence of neuritis and perineuritis by exposing the 
nerves, and worked a gradual cure by stretching their trunks. 

Whatever doubt may exist as to the direct cause of the paralysis, 
the first step in the treatment is to reduce the dislocation ; after that 
has been accomplished, or even if it should fail, electricity should be 
persistently employed. Some cases respond promptly to treatment, the 
contractility of the muscle sometimes reappearing after even the single 
application of a blister, while others, after weeks or months of treat- 
ment, will show no improvement. So long as the muscle reacts to 
electrical stimulation the prognosis is good. 

Bloodvessels. The complication of serious injury to the bloodves- 
sels in the neighborhood of the joint is not frequent, and in the 

bardenheuer: Loc. cit., p. 335. 



DISLOCATIONS OF THE SHOULDER 617 

recorded cases there is often a doubt whether the injury was caused by 
the dislocation or by the attempt to reduce it. The subject has been 
discussed in detail in Chapters XXTX. and XXXIV. 

Chest. A unique case reported by Prochaska, in which the head of 
the humerus was forced into the chest between the second and third 
ribs, is quoted in Chapter XXIX., p. 443. 

Compound dislocations are rare ; the wound in the skin is commonly 
in the axilla, sometimes further inward through the pectoralis major, 
sometimes behind the joint. It is a very serious complication, although 
there is reason to hope that a larger proportion of successes will be 
obtained in the future under the improved methods of treating wounds 
than was possible in the past. The essentials of such treatment are 
immobilization of the joint, drainage, and surgical cleanliness; excis- 
ion of the head of the humerus may also be required under certain 
circumstances, such as difficulty of reduction or retention, coincident 
fracture, uncleanliness of the wound, and imperfect drainage of the 
joint. The prudent course is to provide abundantly for drainage by 
not closing the skin wound except, perhaps, in part, and by lightly 
packing with iodoform gauze for at least twenty-four hours. The last- 
named precaution provides a prompt and ready means of escape for 
the blood and exudations, and at the same time does not prevent the 
wound from being closed a day or two later with sutures and then 
healing as rapidly and kindly as if it were entirely fresh. 

Simultaneous dislocation of both shoulders is deemed a rare occur- 
rence ; possibly it is more frequent than is generally supposed, for I 
found five cases mentioned in the Index Medicus for the years 1880 to 
1885. It is of interest only as a curiosity, for the combination does 
not seriously affect the prognosis or treatment. The causes in the five 
cases referred to were as follows : In one * the patient was seized in 
the street by two thieves who drew his arms upward, outward, and 
backward, producing subcoracoid dislocations ; both joints had pre- 
viously been repeatedly dislocated. In the second 2 the patient, while 
standing on a platform, was caught under one arm by a chain and 
thrown to the ground. In the third 3 a woman, eighty-six years old, 
fell out of bed, receiving an intracoracoid and a subcoracoid disloca- 
tion. In the fourth 4 a girl, twenty-one years old, was knocked down 
by a falling wall ; and in the fifth, 5 a girl, the injuries occurred during 
an epileptic convulsion. In a personal case both shoulders were dislo- 
cated by lifting the patient by his hands out of the water into a boat. 
All of them were anterior dislocations. Mention has been made in 
the preceding chapter of Bardenheuer's case in which both shoulders 
were dislocated backward by a fall forward upon the elbows. Anglada 
(Arch. Interned, de Chir., 1908 II. 6) reports a case and collects mam- 
published ones. 

Associated dislocation of the elbow has been twice reported. Morel- 

1 G. E. Moore : New York Medical Record, 1SS0, vol. xviii. p, 96. 

2 Caskie: British Medical Journal, 1S81, ii. p. S54. 

8 Giiterbock : Berlin, klin. Wochenschrift, 1SS5, vol. xii. p. 340. 

*Zinker: Idem, p. 418. 

5 Frankel : Verhandl. Berlin, med. Gesellschaft, 1SS5, xiii. p. 150. 



618 DISLOCATIONS. 

Lavallee's 1 patient was injured in a railway accident ; the head of the 
humerus was driven out through the skin of the outer part of the 
shoulder and projected so far that the elbow was in contact with the 
axilla ; the elbow also was dislocated. 

Moxhay\s patient was a man, fifty-six years old, who was struck on the 
back of the arm by the handle of a wrench and sustained a backward 
dislocation of both bones of the forearm and a subcoracoid dislocation of 
the shoulder ; the latter injury was not discovered by the surgeon until 
the seventh week after the accident ; it was then successfully reduced. 

Injuries caused by attempts made to reduce dislocations have been 
described in Chapter XXXIV. 

PROGNOSIS AND AFTER-TREATMENT. 

Since our knowledge of the pathology of dislocations and of the 
common obstacles to reduction has become so much more accurate 
and complete, and especially since the introduction of anaesthet- 
ics, failure to reduce a recent dislocation of the shoulder has 
become very exceptional. Bardenheuer says that of 400 such cases 
treated by him within ten years he has not failed in any, and 
only once has he had any difficulty. I have been obliged to resort 
to the knife in only one. The prognosis, therefore, so far as the 
reduction of recent dislocations is concerned, is eminently favorable. 
It is also more favorable for the older dislocations than it formerly 
was, for the same reasons and because of the greater safety of opera- 
tive interference ; and at the same time such cases have become more 
uncommon, for, as a rule, they are now only those in which the dislo- 
cation has been overlooked or not treated. 

The prognosis is also favorable as regards the complete restoration 
of the functions and security of the joint, but this restoration may be 
delayed or prevented by inflammation or partial anchylosis of the 
joint or by paralysis of some of the muscles, and the security may be 
seriously diminished by partial failure of repair or by permanent 
changes in the joint surfaces. 

A recent investigation by Kuttner 3 shows surprisingly unfavorable 
results. Of 54 patients whom he was able to trace, from among 
those treated during the preceding five years, only 7 (13 per cent.) had 
regained full use of the limb without loss of strength or limitation of 
motion; in 14 (26 per cent.), the range of motion was complete but the 
strength, measured with a dynamometer, was reduced one-half or more. 
The remaining 32 (61 per cent.) had some loss of motion, which in 26 
amounted to inability to raise the elbow laterally above the level of the 
shoulder. All the cases were uncomplicated and had been treated in 
hospital, immobilization for a week followed by massage and mechano- 
therapy for two or three months. Kuttner thought it would have 

i Morel-Lavallee : Bull, d? la Soc. de Chir., 1858, vol. viii. p. 490. 

2 Moxhay : Lancet, 1882, ii. p. 938. 

3 Kuttner: Beilage zum Ztlblatt fur Chir., 1908, p. 155. 



HABITUAL DISLOCATIONS OF THE SHOULDER. 619 

been better to shorten the time of immobilization ; it seems to me that 
it would have been better to lengthen it and to have used passive 
motion less early and less freely, for the limitation of motion was doubt- 
less due to periarticular thickening on the inner side, and it seems not 
unlikely that the torn tissues were not allowed sufficient time to regain 
their softness and pliability. 

The after-treatment is directed to the retention of the head of the 
bone in its place until such time as the repair of the injuries to the 
capsule and peri-articular tissues is sufficiently advanced, and to the 
prevention or cure of inflammation and anchylosis. 

It occasionally, though very rarely, happens that the dislocation is 
reproduced within a few minutes of the reduction, without such move- 
ment of the arm (abduction or elevation of the elbow) as would explain 
it, and it is then presumably due to muscular contraction, perhaps aided 
by the interposition of a portion of the capsule. It suggests the de- 
sirability of immediately and securely fixing the arm to the side of the 
body before the patient is allowed to move after reduction has been 
made, and of inspecting the limb shortly afterward. 

The traumatism is always followed by some inflammatory reaction 
and the evidences of a more or less prolonged arthritis, but it seldom 
happens that this is sufficiently violent to cause apprehension or require 
other treatment than immobilization of the limb. The severer cases 
are those in which the limb has been too early or too freely used. 
The fear that prolonged immobilization of a joint would lead to its 
permanent stiffness is, or has been, too prevalent and has led to much 
untimely passive or active motion of joints that have been injured, and 
this in turn, by keeping up the irritation, has increased the stiffness 
which it was designed to diminish. After the soreness has ceased, 
about the third week, the patient should be encouraged to try gently 
to increase the range of motion and freely to use the limb within the 
limits of pain. The retraction of the capsule, the loss of its pliability, 
is, except in the case of prolonged inflammation and in some highly 
arthritic individuals, only temporary and will ordinarily yield to the 
natural use of the limb. 

If the inflammation is more severe or if it has been prolonged by 
imprudent use of the limb the immobilization should be supplemented 
by traction downward. Bardenheuer 1 highly recommends in addition 
that the upper end of the humerus should be kept pressed outward 
and backward by a pad in the axilla attached to a weight above and 
behind the shoulder. This necessitates the recumbent posture. 

For late changes in the bone see the following section : Habitual 
Dislocation. 

Paralysis of the deltoid causes the loss of voluntary abduction of 
the arm, and if prolonged leads to permanent shortening of the lower 
and inner portion of the capsule with consequent limitation of even 
passive abduction. It may also be followed by the sinking of the 
humerus downward through lack of the support normally given by 
the deltoid, and by consequent loss of security in the joint. Usually 

1 Bardenheuer : Loc.cit., p. 412. 



620 DISLOCATIONS. 

these paralyses get well spontaneously or under treatment by blisters 
or electricity, but sometimes they are permanent. 

If the dislocation remains permanently unreduced the peri-articular 
muscles become wasted and the deformity of the region is thereby 
increased. The head forms a new socket for itself, but its availability 
for motion is slight, and the use of the limb is confined, as a rule, to 
the " underhand " movements. In some cases the compensatory mo- 
bility of the scapula is such that the hand can be raised to the head, 
and in some a degree of usefulness has been exceptionally obtained 
that is far in excess of what is usual. Thus, Prochaska's patient, 
the head of whose humerus was lodged in the chest after having 
passed between the second and third ribs, earned his living for many 
years as a woodchopper. 



HABITUAL DISLOCATION. 

Habitual dislocation, by which is meant a marked tendency to the 
reproduction of the dislocation by slight causes, such as the abduction 
of the arm, is not infrequent and may constitute a serious disability ; 
it is most frequently observed after anterior dislocations, but appears 
to be relatively more common after the posterior ones. 

This tendency has generally been attributed, though without anatom- 
ical proof, to laxity of the capsule, itself the consequence of imper- 
fect repair of the rent made in it at the time of the dislocation, but 
the recent researches of Jossel l show, for the forward dislocation, that 
the enlargement of the capsule observed in such cases sometimes takes 
place at its upper portion in consequence of the rupture or avulsion of 
the tendons of the supraspinatus and infraspinatus muscles, which 
involves the rupture of the capsule at the same level and the creation 
of a free communication between its cavity and that of the subcoracoid 
bursa (see Chapter XXIX., p. 445). He found this condition at the 
autopsies of five joints which had been subject to habitual dislocation 
during life and in four other specimens found in the course of an 
examination made with this object of all bodies received in the dis- 
secting-room during two successive winters. 

Turner Thomas 2 found the capsule enlarged at its inner and lower 
portion by defective closure of the rent, and thinks this is the usual 
cause. 

Other specimens have shown important changes in the head of the 
humerus and the glenoid fossa. Lobker 3 presented at the Fifteenth 
Congress of German Surgeons a specimen obtained, post mortem, from 
a case of habitual dislocation, which showed changes in the head and 
glenoid fossa which were thought to be the effect of the frequent recur- 
rence, and another specimen obtained by Vogt by excision in a similar 
case and showing the same changes in the head of the humerus. The 
head in each case was normal only on its inner anterior half; the other 

1 Jossel : Deutsche Zeitschrift fur Chir. , 1880, vol. xiii. p. 167. 

2 Thomas : Am. Jour. Med. Sc., Feb. and March, 1909 

3 Lobker : Beilage zum Centralblatt fur Chir., 1886, p. 90. 




HABITUAL DISLOCATIONS OF THE SHOULDER. 621 

half had lost its. roundness, and showed a depression one eentimetre 
deep and two centimetres wide, extending from top to bottom, and 
separated from the normal inner half by a sharp prominent border. 
The surface Avas covered throughout by cartilage, and the depression 
was evidently not the result of a fracture with loss of substance. The 
tuberosities and bicipital groove were intact ; the long tendon of the 
biceps was torn from its insertion, and had become adherent in its 
groove. There were evidences of the avulsion of the muscles from 
the greater tuberosity. The outer portion of the glenoid fossa was 
normal, and separated by a sharp vertical border from the large inner 
portion which was angularly deflected backward. Both portions were 
covered with cartilage, and showed no sign of fracture. The head 
and fossa fitted together in such a way that the inner half of the head 
articulated with the inner half of the fossa, and 
the sharp edge of the latter occupied the Fig.J305. 

depression in the former. 

He refers to the fact that specimens obtained 
by excision by Cramer, Kiister, and von Volk- 
mann showed similar losses of substance in 
the head of the humerus, and attributes them 
to the frequent recurrence or to a persistent 
subluxation by which the head is made to rest 
against the inner border of the fossa, instead 
of squarely against its face. 

The symptoms presented by Looker's case Horizontal section of the head 

during life are not given, but it does not .Seem of the humerus in Cramer's ease 

possible that they could have been, at least of habitual dislocation a i loss 

" J \ - of substance ; B, greater tuoer- 

at the last, such as are found in habitual dis- sity ; c, lesser tuberosity. 
location, for that is characterized by complete 

restoration of form in the intervals between the recurrences, while in 
this case the subluxation must have been persistent. 

Three cases of habitual dislocation in which the head of the humerus 
was excised are referred to by Lobker as showing similar losses of sub- 
stance in the humerus, but a reference to the original reports 1 shows 
that in all three the loss was thought to be the result of a fracture, 
although in the discussion on one of them (Kiister' s), Riedinger expressed 
the opinion that it was due to absorption. As the cases illustrate also 
the method of treatment by excision, I quote two of them briefly. 

Cramer's patient was a woman thirty years old, who dislocated her 
shoulder forward and inward during an epileptic fit, and again in another 
two months later ; the arm was then immobilized for several months, and 
a special dressing was worn most of the time afterward, especially at the 
menstrual periods, when the attacks of epilepsy were most likely to occur, 
but nevertheless the dislocation recurred nineteen times within five years, 
each time during a fit; reduction was sometimes easy, sometimes quire 
difficult, and the patient was eager to be relieved of the annoyance and 
the dread. The head was excised through an anterior incision, and the 

1 Cramer : Berlin, klin. Wochenschrift, 1SS2, p. 21. Volkmann, report oil by Popke : 
Zur Kasuistik imd Therapie der inveterirten und habituellen Schulterluxationen, 
Halle, 1882. Abstract in Centralblatt fur Chir., 1883, p. 28. Kiister: Beilage ram 
Centralblatt fur Chir., 1882, p. 73. 



622 DISLOCATIONS. 

patient made a good recovery. The functional result was fairly satis- 
factory and was still improving two years after the operation. 

The articular surface of the head of the humerus showed a shallow loss 
of substance on its outer side four centimetres long, two broad, and about 
three-fourths of a centimetre in depth at the centre (Fig. 305), and there 
was found a small body of irregular shape, one centimetre in its greatest 
diameter, with a smooth surface, and attached by a long, thin pedicle to 
the posterior margin of the glenoid fossa. It was composed of bone cov- 
ered by fibrous tissue with bits of cartilage between them in places, and 
was thought to be a fragment broken from the head. 

In Volkmann's the posterior third of the head showed a smooth 
surface not covered by cartilage, which had been " undoubtedly " pro- 
duced by the breaking off of a wedge-shaped piece. No such fragment 
could be found in the cavity, and it was thought to have been absorbed. 
The glenoid articular fossa was altered in shape, having become nar- 
rower below than above. The capsule was torn away from the inner 
and lower margin of the glenoid fossa, thus creating an opening which 
communicated with the subscapular bursa. On the thickened edge of 
this opening was attached, by a sort of pedicle, a piece of cartilage- 
covered bone " which was evidently the remains of a fragment broken 
from the edge of the glenoid fossa." (This, if so, would be a suffi- 
cient explanation of the recurrence.) The patient reported that the 
condition of his arm was much more satisfactory than before the 
operation. 

These changes in the bones are essentially the same as those described 
in cases of chronic, non-suppurative inflammation, in some of which it 
is evident that the process originated in a dislocation. (See Gurlt, 
Path. Anat der Gelenkkrankheiten, pp. 250-267, and especially Curl- 
ing's case, p. 280, also described in the Medico- Chirurgical Transactions, 
1837, vol. xx. p. 336, as a partial dislocation forward.) It seems not 
improbable that the series of observed changes may be started by an 
ordinary dislocation, that is, by one that is not distinguished by any 
exceptional lesion such as partial fracture of the head or of the edge 
of the glenoid cavity ; this is followed by a non-suppurative arthritis 
which so modifies the capsule and the shape of the surfaces that a 
recurrence of the dislocation is made easy. The pedunculated bodies 
composed of bone and cartilage, sometimes found in the joint and 
thought to have been broken from the head of the humerus or the 
edge of the glenoid fossa, may be of new formation. In three of four 
cases reported by Burrell and Lovett, 1 some of the muscles of the 
shoulder were notably atrophied. Additional information has recently 
been supplied by Francke, 2 who collected 18 cases, Hildebrand, 3 who 
operated upon 2, and Perthes, 4 who operated upon 4 cases. Francke 
thinks enlargement of the cavity and relaxation of the capsule the 
main factor; he found a defect in the head of the humerus in 12 of 
the 18 cases, and in the glenoid in 9, a rent in the capsule at the edge 

1 Burrell and Lovett : Transactions of the American Surgical Association, 1897, p. 296. 

2 Francke, Deutsche Zeitschrift fur Chir., vol. 48, p. 399. 
8 Hildebrand : Arch, fur klin. Chir., vol. 66, p. 360. 

* Perthes : Deutsche Zeitschrift fur Chir., vol. 85, p. 199. 



HABITUAL DISLOCATIONS OF THE SHOULDER. 623 

of the glenoid in 3, and rupture of the outward rotators or avul- 
sion of the greater tuberosity in 5, and free or pedunculated bodies in 
the joint in 5. 

Hildebrand found the glenoid defective and the cavity enlarged by a 
pouch on the inner side, and Perthes found rupture of the outward 
rotators in 2, simple enlargement of the cavity in 1, and wide detachment 
of the capsule and periosteum from the anterior edge of the glenoid and 
adjoining part of the scapula in 1. 

The defect in the head is habitually situated at the posterior outer 
portion in the form of a deep sharp depression. It has been interpreted 
as due to the loss of a fragment, to a crush against the edge of the 
glenoid, and to absorption after bruising. 

Hildebrand deepened the glenoid fossa so as to give it a raised inner 
edge and packed the adjoining pouch with gauze in order to cause its 
wall to retract. Perthes reattached the outward rotators to the tuberosity 
in 2 cases, made a tuck in the capsule (Bicard) in 1, and by an ex- 
tensive operation in the fourth reattached the capsule to the glenoid 
margin. 

The frequency of recurrence varies greatly in the different cases; in 
some the intervals are long, in others the dislocation is produced every 
time the elbow is raised, and in some the bone can be voluntarily thrown 
out of place by the contraction of the muscles. 

Ordinarily reduction is very easy, and the patient learns to effect it 
himself; in others it is at times difficult. 

The treatment by injections of iodine and by narrowing the capsule 
on the inner side has been mentioned in Chapter XXXIIL, p. 470. 
The latter has been employed successfully by its introducer, Ricard, 
in two cases, by myself 1 in three, and by Willy Meyer (Annals of Surg., 
May, 1908, p. 811) in one. The incision occupies the interval between 
the deltoid and the pectoralis with an extension from its upper end 
outward close to the acromion ; the corresponding portion of the del- 
toid is detached and turned outward. In the anterior portion of the 
capsule thus exposed two or three sutures of stout silk are passed so as 
to take up a fold about three-quarters of an inch wide and running 
downward and outward, or a long narrow piece is excised. 

In one of my cases the joint was extremely loose, the head slipping 
out easily either in front or behind ; the original injury was of a char- 
acter that ensured extensive tearing of the capsule. After the narrow- 
ing of the capsule in front the head no longer escaped on that side but 
still slipped backward in some positions of the limb ; the patient was, 
however, so satisfied with the usefulness of the limb that he cared for 
no further improvement. 

Burrell 2 obtained an excellent result in two cases by excising from 
the anterior inner portion of the capsule a piece four centimetres long 
and one wide, and closing the gap with catgut sutures. For better 
exposure of the field of* operation he divided the upper three-quarters 

1 Stimson : Annals of Surgery, March, 189S, p. 364. 

2 Burrell and Lovett: Transactions of the American Surgical Association, 1897, 
p. 296. 



624 DISLOCATIONS. 

of the tendon ot the pectoralis major clo.se to its insertion, and part of 
the tendon of the subscapularis. 

Grothe 1 incised the anterior portion of the capsule and narrowed it 
by overlapping the sides of the incision. 

Thomas (quoted above) exposed the capsule through an incision 
in the axilla, passing between the coraco-brachialis and the vessels 
and nerves and dividing the tendon of the subscapularis ; he then 
excised the new tissue filling the gap in the capsule and brought 
the sides of the rent together. The result was excellent. There can 
be no doubt, I think, that in an unknown proportion of cases this is 
the ideal operation, for it removes the predisposing pathological con- 
dition, closes the rent in the capsule, and permits as satisfactory an 
examination of the interior of the joint for other abnormal conditions 
as the anterior approach does. But I do not like the division of the 
subscapularis tendon ; its reunion might easily be defective. In my 
own cases the exposed (antero-inner) portions of the capsule showed no 
signs of previous injury and so little laxity in two of them that at the 
time I hardly dared to anticipate any benefit, and I am still at a loss 
to account for the eminently satisfactory result. But the result teas 
satisfactory, as it was also in the other cases in which the method has 
been employed, and that clinical fact deserves to be taken into account. 

Excision of the head of the humerus has been resorted to in at least 
nine cases, and the reported results in some of them were good. I 
should think the disability would have to be great to justify so radical 
a measure, one which may in itself be so disabling. 

Yeates 2 describes an apparatus which he had worn with comfort and 
advantage to limit the range of motion and thus prevent recurrence. 

Another class of cases in which the tendency to recurrence is the 
result not of a primary traumatic dislocation but of pathological 
changes in the joint or of paralysis of the muscles will be considered 
in a subsequent section. 

TREATMENT OF OLD DISLOCATIONS THAT CANNOT BE RE- 
DUCED BY MANIPULATION AND FORCIBLE TRACTION. 3 

The urgent desire of patients to be relieved of their disability or of 
the pain caused by the persistence of the displacement has led surgeons 
to resort with increasing frequency to cutting operations in the hope of 
restoring the bone to its place or improving its position, or to excise 
the head. Others sought to improve the position of the limb or to 
create a false joint by subcutaneous fracture or division with the saw. 
It is not always easy to determine from the histories of the cases the 
measure of success or improvement, for in some the report ends with 

1 Grothe : Munch, med. Wochenschrift, 1900, No. 19. 

2 Yeates : Lancet, June 30, 1888. 

3 For bibliography see Knapp, Beitrage zur klin. Chir., 1888, vol. iv. ; Schoch, 
Ibid., 1901, vol. xxix. ; Engel, Arch, fur klin. Chir., 1897, vol. Iv. p. 603; Sinital, 
Wiener med. Wochen, 1890, No. 52 ; Gwyer, New York Medical Journal, March 28, 
1891; Delbet, Arch. gen. de Med., 1893; Souchon, Transactions of the American Sur- 
gical Association, 1897; Legueu, l'lndependance med., 1901, No. 15. 



DISLOCATIONS OF THE SHOULDER. 625 

the operation, and in others although the result is called a success the 
description leaves the reader in doubt as to the completeness of the 
reduction or as to the improvement in function. With our more accu- 
rate knowledge of the changes in the condition of the glenoid fossa 
and in its relations with the capsule that follow the prolonged absence 
of the head of the humerus from it, we may well doubt the complete- 
ness of any reputed reduction in old cases obtained by subcutaneous 
measures or feel justified in believing that the benefit attributed to the 
use of the tenotome was a delusion, and that the really efficient agents 
were the manipulation and the traction. In this criticism I do not 
include those tenotomies or divisions of muscles which in the earlier 
days took the place now filled so much more easily and safely by anaes- 
thetics. It is addressed mainly to a method employed by Polaillon l 
in 1882, and subsequently used by some and highly recommended by 
others on his authority. 

Subcutaneous Section. Polaillon's patient had an intracoracoid dis- 
location, produced during an epileptic fit, that had existed for four 
months. An attempt to reduce with the pulleys, aided by chloroform, 
failed, but brought the head of the humerus near its socket and directly 
under the coracoid process. Eleven days later the patient was again 
chloroformed, a blunt-pointed tenotome introduced through a small cut 
made through the skin and muscle a finger-breadth below the tip of 
the acromion, and carried horizontally inward between the deltoid and 
the point of the humerus, its edge turned backward, and then with- 
drawn so as to divide the tissues lying upon the bone ; the point of the 
knife was then carried through the same incision to the back of the 
humerus, and a similar cut made along the outer aspect of the head. 
Two days later the traction was renewed under chloroform, and the 
dislocation reduced. A week later, the bone having meanwhile shown 
a constant tendency to become displaced forward and inw 7 ard, a tourni- 
quet was applied about the shoulder to keep it in place. A month 
later the patient was able to raise his hand to his mouth and to put it 
behind his head, and " the movements were daily gaining in extent." 

It is not so uncommon for a second or third attempt to reduce by 
traction to succeed after the first has failed that the success in this 
case can be unhesitatingly attributed to the subcutaneous division, and, 
furthermore, it seems doubtful whether an incision made from the 
outer side in this manner could divide anything that offered any seri- 
ous obstacle to the return of the bone. The additional cases, in which 
this method was successfully employed by Polaillon, are briefly men- 
tioned in a thesis by Bardon-Lacroze. 2 

An open arthrotomy, by which the surgeon is enabled to see and 
remove the obstacles to reduction, is not only more likely to be suc- 
cessful than subcutaneous division, but, if carefully done when the 
tissues have not been lacerated and inflamed by recent forcible attempts 
to reduce by traction and manipulation, is also, in my opinion, not more 
dangerous. If the conditions prove during the operation to be unfa- 

i Polaillon : Bull, de la Soc. de Chii\, 1882, p. 129. 

2 Bardon-Lacroze : Des sections sous-cutanees comme moyen de reduction des lux- 
ations anciennes du coude et de Pepaule. Thdse de Paris, 1882, No. 209. 
40 



626 DISLOCATIONS. 

vorable, excision of the head can be easily substituted. Souchon's 
statistics show 69 per cent, of the results classed as " fair," " good," 
and " very good " after reduction by arthrotomy. Among unfavorable 
conditions are to be counted fracture of the glenoid cavity or its occu- 
pation by a mass of fibrous tissue, fracture and marked displacement 
of the greater tuberosity, and the -need of extensive dissection to return 
the head to its place. The effect of the latter is shown in the com- 
paratively frequent (16 per cent., Souchon) necrosis of the head after 
reduction. Possibly this could be avoided by keeping the liberating 
incisions well away from the bone. Knapp, reviewing twelve cases of 
reduction by arthrotomy and twenty of excision of the head, advises 
reduction only in comparatively recent cases, excision in the old ones. 
In a number of cases the surgeon has resorted to excision after having 
failed to reduce by arthrotomy. 

In anterior dislocations reduction by arthrotomy may be done by an 
anterior incision along the border of the deltoid, aided if necessary by 
a horizontal extension outward and detachment of the corresponding 
part of the deltoid from the acromion. This gives free access to the 
outer part of the head and capsule and permits the removal of the 
latter from the glenoid fossa if it has become adherent to it, an abso- 
lutely necessary step in many cases. The liberation of the head on the 
inner side and behind is much more difficult, and the inability prop- 
erly to accomplish it appears to have been the cause of the rather fre- 
quent abandonment of the attempt and the substitution of excision. 

The after-treatment requires maintenance of a position that effectu- 
ally opposes recurrence and a rather early resort to very limited passive 
motion. 

Dollinger * recommends an incision on the inner side of the cephalic 
vein from the clavicle to the insertion of the pectoralis major, deepened 
between the deltoid and pectoral until the coraco-brachialis and pec- 
toralis minor are exposed ; these are drawn aside, the humerus rotated 
outward to bring the tendon of the subscapularis into the field, and the 
latter divided. The head can then be easily replaced in its socket. 
He had employed it successfully in seven uncomplicated cases, but 
does not speak of the late results. 

Excision of the head is almost always to be preferred when the dislo- 
cation has been complicated by fracture of either the anatomical or the 
surgical neck, because the resultant conditions — faulty position, increase 
of adhesions — greatly increase the difficulty of reduction and render 
the functional result poor if reduction is effected. It has been done 
by an axillary incision, especially in cases complicated by fracture of 
the anatomical neck.. This method is of comparatively easy execution 
and may properly be used when there is no thought of attempting 
reduction ; otherwise the anterior incision should be used. 

Fracture of the surgical neck of the humerus, which has not infre- 
quently been caused by the attempts made to reduce, has sometimes 
been taken advantage of to place the limb in a better position, and 
Despres z recommends that it should be intentionally produced. Others 

1 Dollinger: Centralblatt fur Chir., 1902, p. 1277. 

2 Despres : Bull, de la Soc. de Chir., 1879, p. 742. 



OLD DISLOCATIONS OF THE SHOULDER. 627 

have done it with the object of subsequently preventing its reunion and 
establishing a false joint between the upper end of the shaft and the 
glenoid fossa. Despres's first operation 1 was done with the object of 
obtaining a pseudarthrosis at the seat of fracture, but bony union took 
place. The usefulness of the limb was, however, so much increased 
by the change in its position that he repeated the operation upon 
another patient merely to effect this change, and was in this case also 
well satisfied with the result. The proposal to generalize the practice 
does not appear to have been received with much favor by his col- 
leagues in the Surgical Society. 

Other features of this subject have been considered in the first part 
of this chapter. 

Dr. J. Ewing Mears 2 divided the surgical neck subcutaneously with 
an Adams's saw and obtained an excellent result by pseudarthrosis. 
His patient was a man, thirty-nine years of age, and the dislocation 
was of two years' standing. The saw was entered on the outer side, 
and the division was easily effected in about five minutes. The case 
deserves to be remembered, and the method is to be preferred to frac- 
turing as less dangerous and more precise. The establishment of a 
false joint would be more certainly effected by the removal of a piece 
of the shaft. 

CONGENITAL DISLOCATIONS. 

This term as commonly employed embraces all dislocations which 
are recognized at birth or which probably existed then, and which 
have no recognizable traumatic cause. They present three distinct 
forms : 1, one due apparently to irregular development of the joint ; 2, 
one in which the bones are normally formed and in which the displace- 
ment may have occurred during delivery ; 3, a third, also with normal 
bones, in which the displacement is the late result of a paralysis 
antedating birth or caused during delivery. While this supposed 
etiology is not completely established, yet the condition of the parts, 
the displacements, and the symptoms of each group are so distinct that 
the grouping is justified even if the etiology should prove to be differ- 
ent. There are, in addition, cases of traumatic dislocation during 
delivery in which the nature of the traumatism is evident and the con- 
dition is immediately recognized and corrected. Some of the paralytic 
forms have been described as " obstetrical paralyses" {vide infra). 
The forms that have been observed are the subcoracoid and, much 
more frequently, the subacromial or subspinous. 

The condition is a rare one ; its relative frequency is shown by Kron- 
lein's collection of 98 congenital dislocations treated in Yon Langen- 
beck's clinic, of which 90 were of the hip, 5 of the shoulder, 2 of the 
head of the radius, and 1 of the knee. I have seen five cases, all 
backward dislocations j four of them, possibly all, belonged in the 
second group above named. 

In support of the theory of a pre-natal origin are the facts that the 

1 Despres : Loc. cit. p. 22. 

2 Mears: Philadelphia Medical and Surgical Reporter, 1S77, vol. xxxvii. p. 287. 



628 



DISLOCATIONS. 



lesion is sometimes double or associated with other congenital defects, 
and that in one case l two children of the same family were similarly 
affected ; and yet it is not impossible that both shoulders or two suc- 
cessive children could receive the same traumatism. 

1st Group. Irregular development. For our knowledge of the 
pathological changes we are indebted to R. W. Smith. 2 In his case of 
double subcoracoid dislocation, a lunatic woman twenty-nine years old, 
" there existed on the left side scarcely any trace of an articulating 
surface in the situation which the glenoid cavity occupies in the normal 
state ; but there had been formed upon the costal surface of the scapula 
a socket of a glenoid shape, measuring about an inch and a half in its 
vertical direction and an inch and a quarter transversely (Fig. 306). 
It reached upward to the under surface of the coracoid process, from 
which the head of the humerus was merely separated by the capsular 



Fig. 306. 



Fig. 307. 





R. w. Smith's case of double congenital sub- 
coracoid dislocation of the shoulder. Scapula of 
left side. 



The same ; left humerus, 

ligament." The glenoid liga- 
ment, perfect in every respect, 
extended all around it. The 
capsule was perfect. 

The head of the humerus (Fig. 
307) a was of an oval shape, its 
long axis corresponding with the 
shaft of the bone. The oval 
shape was principally due to the 
deficiency of its posterior part, 
and there existed between the greater tubercle and the margin of the 
head of the bone, where the investing cartilage terminated, a broad, 
shallow depression corresponding to- the edge which separated the nor- 
mal from the abnormal portion of the glenoid cavity. The shaft of the 
humerus was small and seemingly atrophied." 

Upon the right side, although the condition of the bone was somewhat 
different, the characteristic features of the deformity were similar. 

In his double subacromial case, a lunatic woman forty-two years 
old, "there was no case of a glenoid cavity in the natural situation ; 
but upon the external surface of the neck of the scapula there was a 

1 Scudder : Archives of Pediatrics, April, 1890. 

2 R. W. Smith : Fractures and Dislocations, 1847. 



Oh 




CONGENITAL DISLOCATIONS OF THE SHOULDER. 629 

well-formed socket which received the head of the humerus. It was 
an inch and three-quarters in length, and an inch in breadth ; it was a 
little broader above than below, and its summit was less than a quarter 
of an inch from the under surface of the acromion process. It was 
directed outward and forward, was covered with cartilage, and sur- 
rounded by a perfect glenoid ligament. The tendon of the biceps 
muscle arose from the most internal part of its superior extremity, 
whence it passed downward and outward very obliquely, in order 
to reach the bicipital groove of the humerus. The axillary margin of 
the scapula, if prolonged upward, would have passed nearly altogether 
internal to the abnormal socket. . . . The capsular ligament was per- 
fect. The scapula was smaller than natural, and its muscles badly 
developed." 

The head of the humerus, upon the right side, was of an oval or 
oblong form, somewhat broader above than below ; its anterior half 
alone was in contact with the glenoid cavity. This portion was cov- 
ered with cartilage, the remaining half being rough and scabrous, and 
totally destitute of articular cartilage. The inner edge of the humerus, 
if prolonged upward, would have passed between these two portions of 
the head of the bone." 

" The greater tubercle was natural, but the lesser was elongated and 
curved, forming a most remarkable process ; it was an inch in length, 
and bore some resemblance to the coracoid process of the scapula. At 
its root it presented a smooth, convex, pulley-shaped surface, round 
which passed the tendon of the biceps muscle." The left humerus 
differed from the right only in the smaller size of the lesser tuberosity. 
Both these cases were first seen by Smith upon the autopsy-table, and 
he gives no history as to the length of time the deformity had lasted. 
Both individuals had been for many years inmates of the lunatic asy- 
lum, and the second one was subject to epileptic convulsions, in one of 
which she died. It must be admitted that the appearances are not 
incompatible with the theory of a post-natal origin, perhaps by mus- 
cular action in an epileptic convulsion, as in FrankePs case of double 
simultaneous dislocation quoted above, p. 617. 

The three cases of single subcoracoid dislocation observed during 
life by Smith seem to have been paralytic dislocations. 

2d Group. Subacromial or subspinous, probably caused during 
delivery. These appear to be much the- most frequent ; Gaillard, 
quoted by Malgaigne, 1 reported one, Kiister 2 one of both shoulders, 
Scudder 3 two, I have seen four, possibly five, and A. M. Phelps 4 
reported one case, and told me he had seen six others. Cumston 5 re- 
ports one. My reasons for thinking this group probably traumatic are 
that the limitations of motion closely resemble those of the similar 
traumatic dislocation in adults, and that the bones as shown in a few 
operations and in the radiographs of three of my cases (Plate Lilly 
differ from the normal only in being smaller. In my four cases, Scud- 
der's two, and Cumston's, the right arm was affected, in Gaillard's the 

1 Malgaigne : Loc. cit., p. 569. 

2 Kiister : Em Chirurg. Triennium, 1882, p. 256. 
:! Scudder : Archives of Pediatrics, April, 1890. 

4 Phelps: Transactions American Pediatric Association, 1S95. 
5 Cumston: American Journal Medical Science, June, 1903. 



630 



DISLOCATIONS. 



left ; and it seemed possible that as the right shoulder is in front in the 
great majority of births, the cause might be its pressure against the 
arch of the pubis. Against this, or at least limiting it, is the double 
dislocation in Kuster's and the breech presentation in one of mine. 
Of four cases of head presentation delivery was instrumental in one, 
easy in one, difficult in two. 

Kiister, operating upon one, found the glenoid fossa normally placed 
but small, and the humerus rested on its posterior border. In a case 
I operated upon and in Curnston's the conditions were the same. Dr. 
Phelps told me he had found the fossa defective at its posterior mar- 
gin, as if a piece had been broken off. Radiographs of three of my 
cases show an apparently normal glenoid fossa and humerus, but all 
the bones of the limb, in all four cases, were smaller than those of the 
other. My patients when examined were six, nine, nine, and eleven 
years old ; Scudder's were seven and nine, Gaillard's sixteen, Cum- 
ston's five ; five of the eight were girls. 

Fig. 308. 




Congenital subspinous dislocation of the shoulder. 

The head of the humerus can be seen and felt beneath and behind 
the acromion (Fig. 308), sometimes quite close to its normal position, 
sometimes much further back ; in Gaillard's at about an equal distance 
from the two ends of the spine of the scapula. The elbow is. directed 
forward and a little outward and is markedly rotated inward. This 
position is noted in all and is evidently characteristic. Motion, active 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 631 

and passive, is limited in all directions, especially outward rotation and 
adduction. Scudder's and Cumston's electrical examination of the mus- 
cles showed little difference between the two sides ; in one of mine the 
muscles supplied by the musculo-spiral and musculo-cutaneous nerves 
Avere markedly paretic, in two all were normal, and in one rotation 
of the forearm was weak, but its range was complete. In all my 
cases the condition was noticed at birth ; in one the child cried when- 
ever the limb was handled, but after two months moved it voluntarily. 
In my fifth (doubtful) case, seen in 1886, the delivery was instru- 
mental and very difficult; the child, now dead, was four years old 
when I saw him ; the attitude of the limb was similar to that above 
described, and all voluntary motion at the shoulder was lost ; I classed 
it at the time as an " obstetrical paralysis." 

The treatment in Gaillard's case is interesting : Four times in the 
course of a week he made horizontal traction on the arm by means of 
a weight of sixteen pounds, continued for fifteen or twenty minutes, 
and reinforced occasionally by traction with his hands. On the last 
occasion the head moved an inch and a half along the scapula to the 
edge of the glenoid fossa and was then thrown into it by a movement 
of leverage. It almost immediately came out again. The next day 
it was again reduced and kept in place for an hour. Ten days later 
it was again reduced, and the arm fixed by a bandage ; this time the 
reduction persisted. Two years later the limb was found to have 
gained half an inch in length ; the patient could move it inward, out- 
ward, forward, and backward, could lace her clothes behind her back, 
carry a chair, feed herself, and play on a guitar. 

Kiister operated (excision) upon one shoulder in his double case, 
but the patient, who was fourteen months old, died. I operated upon 
one by an incision along the anterior border of the deltoid with a hori- 
zontal outward extension from its upper end and detachment of the 
anterior half of the deltoid from the acromion. The tendon of the 
subscapularis, which was tightly stretched across the glenoid fossa, 
was divided, and the head brought into place. The change in posi- 
tion made the divided deltoid too short, and it was left unsutured. 
The wound healed primarily, and reduction was maintained. The 
patient, who had been brought from a distance, passed from observa- 
tion at the end of a -month. In the other three cases the usefulness of 
the limb was such, although the attitude was awkward, that I advised 
against operation. Nothing was done in Scudder's cases. Cumston 
used a posterior incision, but did not like it. 

Yon Braman 1 made reduction in a child four weeks old, and bv 
carefully maintaining it for several weeks made it permanent. In 
another patient 13 years old he divided the humerus below the deltoid 
insertion and rotated the lower fragment 90° outward ; this corrected 
the attitude of pronation and thereby improved function. For 3d 
Group, paralytic, see next page. 

iVon Braman: Arch, fur kiin. Chir., vol. 81, part 2, p. 351. 






632 DISLOCA T10NS. 

PATHOLOGICAL DISLOCATIONS AND SUBLUXATIONS. 

Subluxation or complete dislocation may be made easy by changes 
effected in the articular surfaces or the capsule by disease, or by paral- 
ysis of the deltoid or rotator muscles which normally aid in maintain- 
ing the close contact between the bones. The reported instances are not 
very numerous, and even in some of these the evidence, clinical or post 
mortem, has left not only the character and extent of the displacement 
in doubt, but also its essential cause. Such cases do duty with the 
different writers as supposed examples of widely different lesions, such 
as partial traumatic dislocations, new forms of dislocations, and chronic 
arthritis. Gurlt x gives to Adams (Todd's Clyclopoedia, article Shoulder- 
joint) and Canton (London Medical Gazette, 1848, vol. vi. p. 410, and 
vol. viii. p. Ill) the credit of having first shown that cases described 
as partial dislocation by Sir Astley Cooper, Hargrave, and others were 
actually examples of chronic non-suppurative arthritis. In his own 
description of the changes effected by this disease in the quoted cases 
he does not always discriminate between those which were the effect of 
the prolonged inflammation and those which should probably be attrib- 
uted to an antecedent traumatic dislocation which originated the pro- 
cess such as rupture of the tendons of the supraspinatus and infra- 
spinatus and subscapularis muscles, and the establishment of a large 
opening between the cavity of the joint and the subacromial bursa. A 
dislocation recurring after such injuries should be classed with the 
" habitual dislocations." 

Of the three classes made by Volkmann — dislocations by distention, 
by destruction, and by deformity (see Chapter XXXVI.) — the sec- 
ond is by far the most rare, and the third apparently the most common, 
although the distinction between the latter and the first cannot always 
be determined clinically. Indeed, I know of only one recorded case 
in which the history clearly shows an acute non-traumatic effusion in 
the joint promptly followed by an abrupt appearance of the deformity 
with instant relief of the pain, such as has been observed at the hip 
and knee in the course of acute rheumatism or the eruptive fevers. 
The case was reported by Hannon and is quoted by Malgaigne. 2 A 
man forty-five years old who had previously suffered with acute rheu- 
matism in the knee and hip, became feverish, and on the following day 
had an acute inflammation of the shoulder-joint. The pain increased, 
and on the night between the fifth and sixth days became suddenly 
very severe ; the next morning a subcoracoid dislocation was found, 
and was reduced with some relief of the pain. The next day the dis- 
location was found to have partially recurred ; it was again reduced, 
and the limb fixed with a bandage. Recovery followed. 

Malgaigne thinks the over-distended capsule is ruptured on the inner 
side, and thus the dislocation made possible; the view seems insuffi- 
cient to explain the easy partial recurrence. When the effusion is 
more slowly produced and is large the head of the humerus is sepa- 

1 Gurlt : Patholog. Anat. der Gelenkkrankheiten, 1853, p. 250. 

2 Malgaigne : Loc. cit., p. 562. 



PATHOLOGICAL DISLOCATIONS AND SUBLUXATIONS. 633 

rated from direct contact with the glenoid cavity by a layer of liquid, 
the depth of which may amount to one centimetre/ under which cir- 
cumstances it is evident that a slight force would be sufficient to dis- 
place the humerus to either side and without rupture of the capsule, 
just as one easily produces a dislocation in a freshly dissected shoulder 
after making a small opening in the capsule to admit the air. This 
requires relaxation of the scapular muscles which normally hold the 
bones close together, and such relaxation would not be found when the 
arthritis is acute and painful. 

A class of cases, of which quite a number have been reported, are 
sometimes described as traumatic dislocations upward, but Malgaigne's 
opinion that they are the result of arthritis is now generally accepted 
for most of them. They are characterized by the projection of the 
head upward and forward and rigidity of the limb. Malgaigne quotes 
a case to show that the displacement may be caused by carrying the 
arm in a sling that is too short and tight. 

Most of the specimens of dislocation by deformity are open to the 
doubt whether they may not actually be nearthroses following trau- 
matic dislocations, and this is especially true of those in which the dis- 
location is forward. Gurlt 2 describes seventeen specimens concerning 
which this doubt exists, and I think he might well have added to them 
several of those which he describes as examples of chronic inflammation. 

DISLOCATIONS DUE TO PARALYSIS. 

This variety, rare in the adult, has been shown by the investigations 
of Duchenne de Boulogne 3 to be much more common in new-born chil- 
dren, the paralysis being due to the pressure of the forceps or to trac- 
tion in delivery. In consequence of the lack of support which ensues 
upon the paralysis of the muscles of the shoulder, the weight of the 
limb causes it to sink downward, the only remaining support, that of 
atmospheric pressure, being presumably overcome gradually by the 
accumulation of liquid within the capsule. The condition of the joint 
then resembles that of hydrarthrosis, plus the relaxation of the mus- 
cles, and, as has been above described, any slight force is then sufficient 
to displace the head of the humerus to one side. Malgaigne says that 
when all the muscles of the shoulder are paralyzed the displacement is 
always downward and forward, and usually incomplete ; and that when 
the paralysis is partial the displacement is always effected by the action 
of the unparalyzed muscles and is reduced by the weight of the limb ; in 
the only cases of the latter kind of which he had knowledge, two in 
number, the displacement was backward. He saw in a man, thirty- 
four years old, a double paralytic dislocation. 

In new-born children the dislocation is said to be always backward, 
subacromial. Duchenne saw in ten years eight cases of this kind. 
In all the cases of obstetrical paralysis which he had seen the same 
group of muscles was affected, namely, the deltoid, infaspinatite, 

1 Albert: Chirurg. mid. Operat., vol. ii. p. 320. "-' Gurlt : Loc. cit,, p. 274. 
3 Duchenne de Boulogne : De l'Electrisation loealisee, 1871, 2d ed. ; and Panas : Diet 
de Med. et Chir. pratiques, art. Epaule, p. 514. 



634 DISLOCA TIONS. 

biceps, and brachialis anticus ; in some there was also paralysis of the 
muscles in the forearm and hand supplied by the musculo-spiral or 
ulnar nerve. I have seen paralysis of the same muscles (the deltoid, 
biceps, and brachialis anticus) appear spontaneously at the age of one 
year, with consequent laxity of the joint that permitted dislocation 
forward and backward. When the paralysis is caused by the applica- 
tion of the forceps the mechanism appears to be the pressure of the 
edge of the instrument upon the brachial plexus on the side of the 
neck ; in other cases it is the pressure of the linger used as a hook in 
the axilla or to bring down the arm when raised beside the head. 

In one of Duchenne's cases, treated by Chassaignac, a permanent 
cure was obtained by a fixation dressing, worn for five or six weeks. 

Occasionally the disability of the muscles is due to a traumatism 
(myopathic dislocation). In a case reported by Wolff, 1 in which the 
head of the humerus had sunk almost three centimetres below the acro- 
mion, and the disability was very great, the functions of the limb were 
much improved by an operation ; the joint was opened posteriorly along 
the margin of the glenoid fossa, the articular cartilage removed, and 
the bones fastened together with strong silver wire. The control over 
the limb thus obtained through the scapula was such that it could be 
raised and lowered and even a little adducted and abducted. 

1 Wolff: Berl. klin. Wochenschrift, 1886, No. 52. Abstract in Centralblatt fur Chir.. 
1887, p. 637. 



CHAPTER XLV. 

DISLOCATIONS OF THE ELBOW. 

Anatomy — Classification — Dislocations of Both Bones : Backward, lateral, for- 
ward, divergent. 

Anatomy. 

On either side of the lower end of the humerus is a prominence, 
the epicondyle, which can be easily felt, and is of great importance 
in the recognition of any change in the relations of the bones that 
constitute the elbow-joint. The inner one, commonly called the 
epitrochlea, is more prominent and well-defined than the outer one, 
and its upper margin joins the shaft of the humerus by a sharp curve, 
while on the outer side of the shaft the supinator ridge connects the 
side of the shaft with the epicondyle by a gradual slope. Below the 
epitrochlea is the flattened side of the trochlea, projecting downward 
and forward about half an inch, with a sharp, well-defined margin 
which is masked by the ulna when the bones are in place. From this 
edge the articular surface of the trochlea passes outward like a cone, 
its diameter becoming rapidly smaller for about half an inch, and then 
enlarges again, but less abruptly, for nearly an equal distance. Above 
it, posteriorly, is a deep depression, the olecranon fossa, into which the 
tip of the olecranon is received in full extension of the joint, and above 
it, anteriorly, is a corresponding, smaller one, to receive the tip of the 
coronoid process in full flexion. On the outer side of the anterior and 
lower part of the trochlea, and separated from it by a shallow vertical 
groove, is the capitellum, or radial head, of the humerus with which 
the head of the radius articulates, a rounded prominence looking 
directly forward. 

The ulna articulates with the trochlea by its greater sigmoid cavity, 
which has a central longitudinal ridge fitting into the central depression 
of the trochlea, and opposing displacement to either side. 

The radius articulates with the capitellum by the slightly concave, 
circular upper surface of its cylindrical head and with the lesser sig- 
moid cavity on the outer side of the ulna and coracoid process by the 
side of its head. This articular surface on the side of the head is about 
three-eighths of an inch long (from above downward) on the inner and 
posterior side of the bone, the part that is in contact with the ulna in 
supination, but is shorter on the outer side at the part which comes in 
contact with the ulna in pronation. 

The long axis of the trochlear cones and the ovoid capitellum coin- 
cide with one another and represent the axis of the joint for flexion 
and extension ; this line crosses the lower end of the humerus from a 
point just below and in front of the external epicondyle to one that is 

635 



636 



DISLOCATIONS. 



Fig. 309. 



just covered by the lower part of the epitrochlea, and is inclined down- 
ward and inward from the transverse axis of the lower end of the 
humerus, so that the long axis of the forearm does not coincide with 
that of the arm, but deviates to the outer side as it passes downward. 

When the bones are in place and the forearm fully extended the 
uppermost part of the olecranon, the " point of the elbow," lies on 
or close below a transverse line drawn behind the limb from the epi- 
trochlea to the epicondyle ; and when the elbow is flexed at a right 
angle the same point lies a little more than an inch directly below and 
nearly midway between these two prominences in the prolongation of 
the long axis of the shaft of the humerus. Ordinarily the relations 
of these three points to one another can be readily determined, even 
when the region is swollen, and they are the most convenient and 

trustworthy aid in the recognition 
of the existence of a dislocation of 
the ulna. 

The outer border of the head of 
the radius can be felt about three- 
quarters of an inch below the epi- 
condyle in a line drawn from the 
latter to the wrist, and it can be 
felt to move when the hand is 
gently rotated. This is the only 
point where the interarticular line 
is distinctly accessible to palpa- 
tion ; at all other points it is too 
thickly covered by soft parts or 
masked by the parallelism and 
close contact of adjoining surfaces. 
The internal lateral ligament 
arises above from the anterior, 
lower, and posterior portion of the 
epitrochlea and is broadly inserted 
below along the inner margin of 
the greater sigmoid cavity. 

The external lateral ligament, 
shorter and narrower than the in- 
ternal, arises above just below the 
epicondyle and becomes blended 
below with the orbicular ligament that surrounds the head of the 
radius, some of its posterior fibres being continued to the ulna. 

The anterior and posterior ligaments are thin and loose, and close in 
the joint between the lateral ligaments in front and behind, respectively. 
The orbicular, or annular, ligament, placed like a ring about the 
head of the radius and the adjoining portion of its neck, occupies 
three-fourths of a circle of which the remaining fourth is formed by 
the lesser sigmoid cavity of the ulna ; it is thus attached by its two 
ends to the ulna and encircles the head of the radius. It is reinforced 
externally and posteriorly by the fibres of the external lateral ligament. 
The synovial sac extends beyond its lower border for a short distance 




The bones of the elbow: B, the axis of motion 
(Tillaux.) 



DISLOCATIONS OF THE ELBOW. 



637 



along the neck of the radius, and is then reflected upward and attached 
to this bone. 

The ulnar nerve passes close behind the joint on the inner side 
between the olecranon and epitrochlea in close relations with the cap- 
sule and lateral ligament. 

Frequency. 

In order of frequency the dislocations of the elbow come next after 
those of the shoulder and fingers (Chapter XXVIL). 

Kronlein's 109 cases arranged according to age, sex, and variety are 
as follows : 

Table of 109 Dislocations of the Elbow (Kronlein). 





Sex. 


Age. 


Variety. 


M. 


F. 


1-10 


11-20 


21-30 


31-40 


41-50 


51-60 


61-70 


71-80 


Forearm, backward 

Radius, alone 


77 
9 


17 
6 


22 
9 


44 
5 


14 
1 


5 


4 


3 


1 


1 



This shows the same preponderance in males over females, 4 to 1, 
that is shown by dislocations in general, and that the great majority, 
80 out of 109, occur during the first twenty-four years of life. Atten- 
tion was called in Chapter XLII. to the difference in respect of age 
between dislocations of the elbow and those of the shoulder, the latter 
being rare at the age when the former are common, and most frequent 
in middle life ; and Kronlein's opinion was there quoted that fractures 
of the clavicle are in childhood the equivalent injury — that is, are pro- 
duced by the same cause — of dislocations of the shoulder by direct 
violence in middle life, and that dislocations of the elbow are the 
equivalent injury of dislocations of the shoulder by indirect violence. 
Another possible explanation of the frequency in childhood is, I think, 
the hyperextension of the joint which is marked at that age and is 
usually wholly lost in adult life, at least in males. 



Classification. 

The different forms of dislocation of the elbow are numerous, for 
the two bones of the forearm may be displaced together in any one of 
the four principal directions, or each may take a different direction, or 
either may be dislocated while the other remains in place. The num- 
ber of named forms has been still further increased by making in some 
a distinction between " complete " and " incomplete " which not only 
is not justified by any corresponding important pathological or clinical 
difference, but which also does not even correspond with the definition 
of " incomplete " given by those who make most use of the term. 

Many of the varieties are closely allied to one another, and produced 
by causes that differ very slightly. Thus, if the joint is hyperextended, 
the ligaments torn, and a backward dislocation of both bones begun, 



Dislocations of the 
forearm on the 
arm, 



638 DISLOCATIONS. 

the final position taken will vary with the direction in which the force 
continues to act, and with the addition to it of lateral flexion of the 
joint or rotation of the forearm, so that forms as widely different in 
appearance as direct backward dislocation, lateral dislocation, and diver- 
gent dislocation may be produced. It will be proper, therefore, as 
well as convenient, to describe under the more common type, backward 
dislocation of both bones, much that concerns many of the other forms, 
and to limit the descriptions of the latter mainly to the points of differ- 
ence. 

The classification which will be here followed is the same in its prin- 
cipal features as those adopted by most recent writers. The differences 
are in the grouping and recognition of the varieties. 

Dislocations backward, 

backward and outward. 

backward and inward. 
Lateral dislocations, 

incomplete j 1 ^^ 

complete outward. 
Forward dislocations, 

incomplete, or 1st degree. 

complete, or 2d degree. 

with fracture of the olecranon. 
Divergent dislocations, 

antero-posterior. 

transverse. 

f 1, 2. Backward and) 1. Incomplete, or 1st degree. 
Dislocations of the J upward, \ 2. Complete, or 2d degree, 

ulna alone, 1 3. Backward and outward, behind radius. 

[ 4. Forward. 

f 1. Backward. 

Dislocations of the ' | °£j£jj 

radius alone. ( 4 By elongation> or the su bl„xation of children, 

t 5. Associated with fracture of the ulna. 

Congenital and pathological dislocations. 

DISLOCATION OF THE FOREARM BACKWARD. 

This is the most common of all dislocations of the elbow. It is 
habitually produced by a fall, but although the examples are so numer- 
ous the mechanism or mode of production has been the subject of much 
controversy, largely due to the resort to hypotheses which was stimu- 
lated by the lack of definite knowledge. Few who fall are able to 
describe the circumstances of the fall, to say whether the arm was fully 
extended or partly flexed, whether the violence was received upon the 
hand or upon the elbow, and a preconceived theory in the mind of the 
surgeon is a great help to the discovery of facts that favor it. 

The theory of production by forced flexion is supported, so far as I 
know, by only one case, and that a case that has only recently been 
reported. Stetter 1 had a patient who, while working in a mine, was 
caught under a falling stone in such a way that his left elbow was 

1 Stetter : Compendium der Lehre von den Luxationen, 1886, p. 43. 



BACKWARD DISLOCATIONS OF THE ELBOW. 639 

forcibly flexed between the stone and the wall and was dislocated back- 
ward. When seen, about an hour afterward, the joint was in the posi- 
tion of extension. Reduction was easily effected by traction, and 
recovery took place without incident. Fracture of the coronoid process 
could not be recognized. 

The theory of direct displacement backward ("glissement") formu- 
lated by Boyer, and at one time widely held, has not withstood the 
criticism of later writers and is no longer accepted in explanation of 
dislocations caused by falls. A case reported by Weber nearly fifty 
years ago, and much quoted since, is an example of production in this 
manner, but not in a fall : a young man, wishing to show his strength, 
held his arm extended while another tried to bend it ; the latter not 
succeeding, struck the front of the upper part of the forearm violently 
with his fist, at the same time pressing the wrist forward, and caused a 
dislocation which could not be reduced. In like manner, the disloca- 
tion can be produced by a blow upon the back of the arm just above the 
elbow, as in a case quoted by Malgaigne from Flaubert, in which the 
patient's arm was caught under an overturned wagon, and in another 
seen by Hamilton. A similar mechanism has also been observed in 
outward dislocation. 

The theory of torsion presented by Malgaigne, according to which 
the patient in his fall strikes upon the inner side of the slightly flexed 
forearm and the elbow, the limb being somewhat abducted, is perhaps 
true of some cases. Malgaigne's explanation is very brief; he simply 
says the dislocation is effected by " a movement of torsion which brings 
the coronoid process successively inward, downward, and backward." 
However obscure the explanation may be, and it suggests an origin in 
speculation rather than in observation, the fact remains that in a few 
well-authenticated cases the violence has certainly been received upon 
the upper and inner part of the forearm and not upon the palm of the 
hand. Pingaud l quotes three such : a rider falling with his horse and 
dislocating his elbow while the hand still held the bridle ; a man falling 
in the gymnasium with his forearm bent behind his back ; another fall- 
ing backward and rolling upon his side while his hand held his cloak 
together in front of his chest. 

Hyper extension and Abduction. It is now generally believed that the 
injury is habitually caused by a fall upon the palm of the outstretched 
hand, the elbow being in complete extension, and that the primary 
rupture of the ligaments which makes the dislocation possible is 
effected by hyperextension of the joint. That this was a possible cause 
was known to Petit, who had seen a compound dislocation thus pro- 
duced ; and Desault and Bichat, anticipating in this, as in so many 
other things, the slower judgment of the profession, declared it to be 
the common mechanism, but the investigations which first satisfactorily 
demonstrated it were made by a young German surgeon in 1844, 
Roser. 2 His results were quoted and his experiments repeated and 
extended toother than backward dislocations by Streubel, 3 and to these 

1 Pingaud : Diet. Encyclop. des So. Med., art. Coude, p. 496. 

2 Roser: Arch, fiir physiolog. Heilkunde, 1844, Heft 2, p. 185. 

3 Streubel : Prager Vierteljahrschrift, 1850, vol. i. p. 1. 



640 DISLOCATIONS. 

two papers and the articles by Denuce 1 and Pingaud, above men- 
tioned, the reader is referred for details to which space cannot here 
be given. 

Experiment upon the cadaver shows that when this action, of a fall 
upon the outstretched hand, is imitated, the hand being supinated, the 
anterior portion of the internal lateral ligament becomes tense and then 
yields, usually at its upper insertion ; then, as the movement is con- 
tinued, the rupture extends along the anterior ligament, perhaps 
involving part of the brachialis anticus, the elbow bends inward, and 
if pressure is made downward upon the head of the humerus this bone 
passes down in front of the coronoid process and radius, and a back- 
ward dislocation is produced. 

In whatever direction the force may act it is evident that its first 
effect must be to rupture one or both of the lateral ligaments, for they 
are the ones which hold the bones together and they oppose not only 
lateral motion but also hyperextension. According as one or the other 
of these is first, or alone, torn, and according to the direction of the 
force, the details of the position in which the bones come to rest will 
vary and the displacement will be directly backward or to either side 
or with more or less abduction or adduction of the forearm. 

The frequency with which the tip, or more, of the internal epicon- 
dyle is broken off and the flexors of the hand detached from it and the 
adjoining bone, and with which the external lateral ligament remains 
continous with the periosteum stripped up from the back of the 
external condyle, convinces me that forcible abduction of the forearm, 
during either extension or partial flexion of the elbow, is the first step 
in the production of the injury in a large number of cases ; this breaks 
the internal lateral ligament and frees the ulna, and then the bones slip 
past each other, the external lateral ligament being torn or detached in 
the movement, and the head of the radius tearing off the corresponding 
portion of the capsule and adjoining periosteum as it slips up behind 
the condyle. 

The cases in which the coronoid process and the portion of the head 
of the radius which is anterior at the moment are broken off show that 
in them the direct impulsion of the bones past each other was effected 
by great violence acting along the axis of the forearm before these two 
parts had entirely cleared the lower surface of the humerus. 

In one case that came under my observation the dislocation w r as 
effected by hyperextension and torsion without the aid of the weight 
of the body to press the humerus downward. The patient, in jumping 
down from his wagon, steadied himself by grasping the rail of the 
seat, and, the height being considerable, the wrench was sufficient to 
dislocate the elbow. 

Pathology. The internal lateral ligament is always torn, usually at 
its insertion upon the humerus, and the rent extends along the anterior 
ligament. The external lateral ligament is usually torn or detached 
from the humerus ; its partial preservation in some cases notably affects 
the attitude of the limb and may create considerable difficulty in reduc- 
tion. The orbicular ligament is rarely injured. 

1 Denuce: Diet, de Med. et Chir. prat., art. Coude, 



BACKWARD DISLOCATIONS OF THE ELBOW. 64J 

The tip of the internal epicondyle is frequently torn off, apparently 
by avulsion through the attached flexor muscles ; when the fragment 
is large it remains attached to the internal lateral ligament and is dis- 
placed upward and backward. 

The flexor muscles of the hand are sometimes quite freely torn from 
the humerus, the brachialis anticus is sometimes lacerated and in ex- 
treme displacements torn across ; the tendon of the biceps occasionally 
slips around the outer side of the external condyle. In the only case 
in which I have seen all these extensive lesions the end of the humerus 
was stripped of all its muscles and had passed through the fascia and 
lay under the skin in the fold of the elbow, but the patient had been 
subjected to three attempts by different surgeons to reduce under ether, 
and the lacerations may have been in part due to those attempts. 

The capsule at the back of the external condyle is torn off by the 
edge of the head of the radius and seems frequently to maintain its 
continuity with the adjoining periosteum, which latter is stripped up 
for some distance and caps the head of the radius in its new position. 
This stripping up of the periosteum and its effect in producing new 
bone if the dislocation remains unreduced, which I pointed out in 
the first edition, I have repeatedly observed since. (See Chapter 
XLVII.) 

The displacement of the bone varies greatly, both in extent and in 
direction. The top of the coronoid process may rest against the lower 
and posterior surface of the trochlea, and the radius still remain in 
contact with the under surface of the capitellum by the anterior por- 
tion of its disk, or the latter may be entirely dislocated and rest against 
the posterior face of the external condyle. 

When the ulna is more and the radius less displaced the deviation of 
the wrist is to the inner side ; and when both bones are completely dis- 
placed backward deviation of the wrist to either side will incline their 
upper ends to the opposite side, and thus bring them nearer to the 
internal or the external epicondyle respectively. 

If, in the production of the dislocation, the lateral outward flexion 
is more marked than the hyperextension, the capitellum slips along 
the head of the radius to its inner side, and the latter lodges on the 
outer surface of the former just below the epicondyle, while the coro- 
noid process rests against the posterior surface of the external condyle, 
having been carried outward by pronation of the forearm. The long 
axis of the forearm is deviated to the inner or the outer side ; the 
internal lateral ligament is freely torn. This is the dislocation back- 
ivard and outtvard, classed by some with the outward, by others with 
the backward dislocations, and sometimes misleadingly reported as a 
pure outward dislocation. 

Complications. Fractures of the olecranon, the coronoid process, the 
head, shaft, and lower extremity of the radius, and the epitrochlea have 
been observed in connection with dislocation backward. Fi-acturc of 
the olecranon is effected, presumably, by the pressure of its tip against 
the back of the humerus when the posterior part of the lateral liga- 
ment proves stronger than the bone, and a fracture is produced with 
angular deformity and crushing of the posterior portion of the bone 
41 



642 DISLOCATIONS. 

at the seat of fracture. In a case reported by W. H. Daly l of frac- 
ture of the olecranon, and probably of the coronoid process also, the 
coexistence of a Colles's fracture at the wrist indicated that the injury 
was produced by a fall upon the extended hand. 

Fracture of the coronoid process is probably produced when the 
momentum of the fall forces the humerus downward before the hyper- 
extension has quite carried the tip of the process past the trochlea; and 
Lotzbeck's experiments indicate that it can also be caused, when the 
elbow is slightly flexed, by the direct impulsion of the lower end of 
the humerus in a direction parallel to that of the long axis of the 
forearm. As the brachialis anticus is attached, not to the tip of the 
process, but to its anterior face and the adjoining surface of the ulna, 
the displacement of the fragment is usually slight. 

Partial fracture of the head of the radius has been observed in a 
number of cases, often associated with fracture of the coronoid process. 
It has been described in Chapter XX. The portion broken off is the 
anterior or inner third, and the fracture is effected by the direct press- 
ure of the condyle brought to bear upon the periphery of the disk by 
the displacement backward of the latter. 

One case of fracture of the shaft of the radius and three of fracture 
of its lower end, Colles's fracture, complicating backward dislocation 
of the elbow, are reported in a thesis by Dupuy. 2 

The dislocation may be made compound by the projection of the trochlea 
through the skin in the fold of the elbow, and the brachial artery, and 
perhaps even the median nerve, may be ruptured. In a case reported 
by Ledderhose, 3 in which the dislocation was made compound by a trans- 
verse wound in the fold of the elbow, the musculo-spiral nerve was torn. 
Five months later the nerve was successfully reunited by suture. 

In another, reported by Ferret, 4 the median nerve, exposed for more 
than three inches in the wound and tightly stretched, sloughed. 

Symptoms. The elbow is usually flexed at an angle about midway 
between complete extension and flexion at a right angle, but it may be 
completely extended, or even hyperextended, as in a case reported by 
Morel-Lavallee. 5 The limb is shortened, and if viewed from behind 
the shortening appears to be in the arm, because of the elevation of 
the olecranon, but if viewed from in front in the forearm. If a few 
hours have passed since the injury was received, the region of the 
elbow is occupied by a swelling which may be so great as completely 
to mask the bony points and the characteristic changes in outline ; but 
if this swelling is slight or absent the antero-posterior diameter of the 
joint appears increased, and the transverse diameter unchanged. The 
lower part of the triceps curves backward in the median line to the 
end of the olecranon, creating a hollow on either side, in the outer one 
of which may be seen a slight elevation marking the position of the 
head of the radius. 

1 Daly : Philadelphia Medical and Surgical Reporter, 1880, vol. xliii. p. 71. 

2 Dupuy : These de Paris, 1882, No. 151. 

3 Ledderhose: Deutsche Zeitschrift far Chirurgie, vol. xxv. p. 238, abstract iu Cen- 
tralhlatt fur Chirurgie, 1887, p. 732. 

4 Ferret : Progres Medical, May 7, 1887. 

5 Morel-Lavallee ; Bull- de la Soc. de Chir., 1856, vol. vii. p. 9. 



BACKWARD DISLOCATIONS OF THE ELBOW. 



643 



The front of the joint appears full, and the forearm just below it is 
broadened by the shortening of the muscles that arise from either 
condyle. Sometimes the outline of the trochlea can be distinctly felt 
or even seen, but ordinarily it is masked by the overlying muscles. 

The forearm may take any attitude between pronation and supina- 
tion, for, as voluntary rotation is possible, the patient places it in the 
most convenient attitude. The axis of the forearm may be deviated 
to either side (Fig. 310). 

Flexion and extension are possible within variable, but always nar- 
row, limits and painful ; and when flexion is made the prominence of 
the olecranon behind the joint is increased. Abnormal lateral mobility 
of the joint exists. 

If now the positions of the two epicondyles and the tuberosity of 
the olecranon can be recognized, it will be seen that the latter is dis- 
placed backward and upward, rising, if the 
limb is extended, above the horizontal line Fig. 310. 

joining the epicondyles, or projecting far 
behind a frontal plane passing through 
these two points if the limb is partly 
flexed. This backward projection of the 
olecranon will be increased by flexion of 
the elbow, and at the same time it will 
descend ; while by extension it will be 
moved to a higher level and brought nearer 
the back of the humerus. 

The head of the radius can be felt, per- 
haps even seen, under the skin below and 
to the outer side of the olecranon close 
behind the external condyle, and can be 
recognized by the concavity of its upper 
surface and felt to move under the finger 
when the wrist is gently rotated. 

On the inner side, if the swelling is not 
too great, the finger passing forward and 
downward from the tip of the olecranon 
successively recognizes the curved inner 
margin of the great sigmoid cavity, possi- 
bly also the coronoid process and the back 

of the trochlea, and then moving around the inner side below the 
epitrochlea to the front may trace the sharp circular 
trochlea and recognize its rounded surface and groove in front. 

Diagnosis. The diagnosis should be made upon actual recognition 
by palpation of the position of the two epicondyles, the olecranon, and 
the head of the radius. The surgeon should never be satisfied with 
less than that, and if it cannot be obtained lie should refuse to make 
a positive diagnosis. No attitude of the limb, no measurements, no 
apparent changes in its diameter, no considerations of abnormal 




Dislocation of the elbow backward. 



margin of the 



mobility or fixation are sufficient, and the surgeon who trusts to them 

already too long series of limbs 



/ am 
will be only too likely to add to the 
crippled in consequence of errors in 



644 DISLOCATIONS. 

Of the different fractures that have been mentioned as complica- 
tions, those of the olecranon and epitrochlea are easily recognized by 
manipulation ; that of the coronoid process is indicated by easy recur- 
rence of the dislocation after its reduction, but if the patient is ether- 
ized at the time this symptom is by no means characteristic, and, fur- 
thermore, it is also present in those fractures of the internal condyle 
which are complicated by displacement of the fragment and disloca- 
tion of the radius backward. Fracture of the head of the radius can 
hardly be recognized unless the fragment should be so displaced that 
it can be felt on the outer side of the condyle. 

The records of discussions over cases presented to the various learned 
societies show very clearly the difficulty of making a diagnosis in cases 
that have remained unreduced for any length of time, especially in 
children in whom the injured or stripped-up periosteum rapidly forms 
new bone which obscures the original outlines. Much of the uncertainty 
concerning the character and results of reported cases is due to this fact. 

Prognosis. The prognosis is favorable; reduction in recent cases may 
be confidently expected, with complete or almost complete restoration 
of function. In old cases, of more than six weeks' standing, the prob- 
ability of reduction is greatly diminished, although successes have been 
reported after three, five, and even seven months. The greater the 
displacement upward, the arm being only slightly flexed, the less is the 
probability of reduction after the lapse of some time, for the lacerated 
lateral ligaments have then formed new attachments at points so high 
on the humerus that they must be again ruptured before the ulna and 
radius can be brought below the end of the humerus, and in attempting 
to rupture them by flexing the elbow the olecranon or trochlea mav be 
broken. In addition, the sigmoid cavity fills up with fibrous tissue 
which obliterates its articular surface and binds it to the back of the 
humerus. Furthermore, as the injury is most frequent in the young, 
whose periosteum is active to produce bone when irritated or stripped 
up, obstacles may thus be created which cannot be overcome except by 
arthrotomy. In some cases of unreduced dislocation the patients have 
in time obtained a free range of motion and a useful limb, but usually 
the mobility is very slight. In a discussion upon the subject in the 
Societe de Chirurgie (Bulletins, 1861, p. 103), it was stated as the 
experience of several of the members that, in the older cases at least, 
it was not uncommon to fail to make a complete reduction of the 
radius, but that nevertheless the patients recovered full use of the joint. 
Recurrence of the dislocation of the radius alone has also been observed. 1 

Even after an early reduction the mobility may be diminished by 
the results of the arthritis, especially in the old and rheumatic, or by 
new formations of bone about the joint which mechanically limit its 
range of motion, or, very exceptionally, by an ossifying myositis of the 
brachialis anticus. 2 

Machol 3 observed this myositis in sixteen consecutive cases. He ex- 
amined them all carefully with the aid of the x-rays. The lump ap- 

1 Mason : New York Medical Record, 1880, vol. xix. p. 398. 

2Mysch; Deutsche Zeitschrift fiir Chir., 1899, vol. liv. p. 207; Sudeck: Beilage 
ram Centralblatt fiir Chir., 1901, p. 137. 

a Machol: Beitrage zur klin. Chir., vol. lvi. p. 775. 



BACKWARD DISLOCATIONS OF THE ELBOW. 645 

peared about the end of the first month, increased through the third 
month, and then diminished in size and grew harder. In some a bony 
connection appeared to form between the lump and the humerus, and in 
these the interference with function persisted ; but in most no such 
connection appeared, function improved and the lump gradually disap- 
peared. Franzenheim l says the tumor may reappear after removal. 
Machol thinks a contributing cause is damage done the muscle during 
reduction. 

Compound dislocations usually do well if kept surgically clean and 
well drained, and the limb suspended ; primary resection, in the ab- 
sence of special indications, should not be done. 

Treatment. Much less attention has been paid in the treatment of 
dislocations backward of the elbow to the obstacles created by the 
untorn ligaments than in those of the shoulder or hip, and methods 
are in general and successful use that are directly opposed in character 
to those based upon a consideration of such obstacles and upon the 
principle that a dislocated bone should be returned along the route by 
which it has been displaced. The explanation of this success of faulty 
methods is to be found either in an extensive primary laceration of 
both lateral ligaments or in the possible overcoming of the obstacles 
by increasing the laceration. The easy reduction of most dislocations 
under ether by direct pressure in suitable directions upon the projecting 
ends of the bones is an indication that ligamentous obstacles of impor- 
tance do not exist and that the chief opposition is furnished by the 
muscles spasmodically contracted on all sides of the joint, and the 
inference is too often drawn that, provided this opposition is overcome 
by force or by anaesthesia, the surgeon need not particularly concern 
himself with the attitude of the limb during his efforts to reduce. 
But the success of a faulty method should not make us unmindful of 
its defects ; our work should be done skilfully, as well as successfully, 
and even if our errors will pass undetected and their consequences be 
promptly repaired, we should not lightly commit them. 

Such a generally successful but faulty method is that in which the 
forearm is flexed as nearly as possible to a right angle, drawn directly 
away from the humerus in the direction of the long axis of the latter 
until the tip of the coronoid process is brought below the trochlea, and 
then, the traction being relaxed, is moved forward and upward into 
place. Many different methods of effecting this manoeuvre have been 
employed, the one commonly known as Sir Astley Cooper's, although 
practised in exactly the same manner long before his time, in which the 
surgeon's knee is placed in the bend of the elbow, being the most com- 
mon. Cooper's description of it is as follows : 2 " The patient is made to 
sit down upon a chair, and the surgeon, placing his knee on the inner side 
of the elbow-joint, in the bend of the arm, takes hold of the patient's 
wrist, and bends the arm. At the same time he presses on the radius 
and ulna with his knee, so as to separate them from the os humeri, and 
thus the coronoid process is thrown from the posterior fossa of the 

1 Franzenheim : Deutsche Med. Woehenschrift, 19US, No. 12. 
2 Cooper: Loc. cit., p. 382. 



646 DISLOCATIONS. 

humerus ; and whilst this pressure is supported by the knee the arm 
is to be forcibly but slowly bent, and the reduction is soon effected. 
It may also be accomplished by placing the arm around the post of a 
bed, and by forcibly bending it while it is thus confined." 

The knee is thus used as the fulcrum of a lever of which the wrist 
is at the end of the long arm, and the olecranon at that of the short 
one. The resistance to be overcome is that of the muscles and of the 
soft parts which bind the ulna and radius to the humerus, and it must 
be overcome to an extent that will allow the ulna to be directly sepa- 
rated from the lower border of the humerus to a distance equal to the 
height of the coronoid process, more than half an inch ; the lateral 
ligaments, the upper fibres of the anconeus, and the stout fascia on the 
outer side of the elbow, must all yield to this extent. That they com- 
monly do so is a proof of the amount of the laceration and of the 
force employed. The method is faulty because it requires for its 
accomplishment a maximum of laceration on both sides of the joint 
which may have, and probably has, been escaped in the original injury, 
and because it requires the simultaneous elongation of the muscles of 
the front and back of the arm. Possibly forcible pronation of the 
upper part of the forearm, facilitated by the rupture of the internal 
lateral ligament, would make it easier thus to disengage the coronoid 
process and avoid additional laceration on the outer side. 

The specific objection made to this method applies equally to all in 
which reduction is made while the elbow is flexed at a right angle, and 
in a less degree to those in which the joint is partly flexed. In the 
latter the modes of application of the force are numerous and varied : 
traction by pulleys, by the hand, or by a loop placed above the olecra- 
non, and pressure by the thumbs upon the olecranon and head of the 
radius while the fingers are interlocked in front of the lower end of 
the humerus. The more extended the limb the more easily will 
methods of this kind succeed, but they need to be supplemented by 
flexion or direct coaptation after the coronoid process has been brought 
sufficiently low. 

A possible obstacle in the way of traction in the extended or slightly 
flexed position is the engagement of the tip of the coronoid process in 
the olecranon fossa of the humerus in such a way that its under sur- 
face rests directly against the upper posterior portion of the trochlea 
and prevents the ulna from moving bodily in the direction of its long 
axis. It can be disengaged by pronating the upper part of the fore- 
arm, hyperextending the elbow, or pressing the upper part of the 
forearm backward and the lower part of the arm forward. Except 
for this possible obstacle traction in complete extension meets the indi- 
cations sufficiently and without needless increase of the laceration, and 
the obstacle can be readily overcome, as has just been said, by slight 
hyperextension as suggested by Roser in 1844. 

Traction may be made by the hands of the surgeon himself, or by 
assistants while the surgeon watches the descent of the ulna, frees the 
coronoid process if necessary, and presses the radius and ulna forward 
into place at the proper time ; or it may be made by an India-rubber cord 
or by fastening a weight to the wrist and allowing the arm to hang down. 



BACKWARD DISLOCATIONS OF THE ELBOW. 047 

This method, traction upon the fully extended or even hyperextendcd 
forearm, followed by direct pressure forward on the upper ends of the 
ulna and radius and counter-pressure backward on the lower end of 
the humerus, or simply by flexion, corresponds as nearly to the funda- 
mental principle of reduction as is practicable in the usual uncertainty 
as to the exact attitude taken by the limb at the moment of dislocation. 

In all cases of doubt or difficulty anaesthesia should be used ; and, as 
a general rule, whenever a lateral displacement is associated with the 
backward one the bones should be pressed sideways into line before 
they are drawn downward. 

When the lateral element of the displacement is very marked and it 
is probable that the primary dislocation was directly outward and has 
been followed by a consecutive displacement backward, anaesthesia 
should not be omitted, and after full relaxation has been obtained the 
first attempt should be to move the olecranon and head of the radius to 
the radial side of the humerus and transform the dislocation into a pure 
outward one. By so doing the principle of replacing the bones by the 
route along which they have been displaced is followed, and the risk 
of engaging the tendon of the biceps behind the external condyle is 
avoided. (See also the following section.) If the attempt, cautiously 
made, does not succeed, the surgeon should next seek to change the 
displacement into a pure backward one and reduce as before described. 

If some time has elapsed since the accident, more than ten or fifteen 
days, it may be desirable to break up such adhesions as have formed 
by flexion, extension, and lateral flexion, but it must be borne in mind 
that forced flexion always carries the risk of fracturing the olecranon. 
This is sometimes intentionally done to facilitate reduction in old cases ; 
it is of course followed by more or less loss of the power of active 
extension. The trochlea also has been thus broken. 

Fracture of the coronoid process requires no special treatment ; appar- 
ently the fragment is seldom, if ever, much displaced, for it retains its 
connection with the capsule and, after reduction, is steadied between 
the lower end of the humerus and the tendon of the brachialis anticus. 
The special indication arising from it is to guard against a recurrence 
of the dislocation, which is best done by keeping the elbow flexed at 
or even within a right angle. A posterior moulded splint is an addi- 
tional safeguard. 

Fracture of the olecranon requires the special treatment proper to 
that injury, but as the extended position of the joint, which is most 
favorable for the prompt and close repair of the fracture, exposes to a 
partial or even complete recurrence of the dislocation, it must be avoided 
until after the rupture of the lateral ligaments has been in great part 
repaired. If, in the flexed position, the olecranon is separated from 
the ulna it should be drawn down and held in contact by adhesive 
plaster, or the fracture should be exposed and the fragments sutured. 

Fracture of the head of the radius requires prolonged rest of the 
joint, with a view to reunion if the fragment remains in place ; if 
displaced and readily accessible the fragment should be removed. If 
the fragment should remain on the inner side of the joint, between the 
radius and ulna, it would be most easily reached through an anterior 



648 DISLOCATIONS. 

incision, in making which, however, special care would have to be 
taken to avoid injury to the musculo-spiral nerve and its two branches, 
the radial and posterior interosseous. In one case I operated a month 
after the accident, because of stiffness of the joint, and found a small 
piece of the head displaced to the front of the neck and united there. 
I removed it and all adhesions and covered the raw surfaces with silver 
foil in the hope of preventing fresh adhesion. Two-thirds of the rota- 
tion was preserved. 

Fracture of the epitrochlea requires that the muscles of the forearm 
that arise from this prominence should be kept relaxed. 

If the dislocation is compound, but without laceration of the soft 
parts so extensive as to make amputation unavoidable, the parts must 
be thoroughly cleansed and replaced, efficient drainage provided through 
the wound or through counter-openings, and the limb immobilized in 
a plaster splint and suspended. Some, perhaps extensive, suppuration 
is probable in the soft parts, but the joint is likely to escape so far as 
to preserve a fair amount of motion. Even if the brachial artery is 
torn the limb may still be saved ; and although the additional compli- 
cation of rupture of the median nerve has been thought to make 
amputation necessary, I think a different view would now be taken 
and the attempt would be made to reunite its ends. Fortunately 
both complications, especially the latter, are very rare. 

After-treatment. In uncomplicated cases it is necessary only to 
retain the limb in a sling for two or three weeks, or until such time as 
the dependent position does not cause pain. Passive motion, to prevent 
anchylosis, is not necessary, and is actually harmful during the first 
fortnight if it causes pain. The limb may safely be immobilized until 
the injury to the capsule and ligaments shall have been repaired. It 
will be more or less stiff when first taken out of the dressings, but com- 
plete restoration of its functions may be confidently expected under daily 
use. Exceptions to this complete recovery are sometimes found in the 
old and rheumatic, in complicated cases, and in the young if the peri- 
osteum has been extensively stripped up. In the first class, the old 
and rheumatic, gentle passive motion strictly confined within the limits 
beyond which persistent pain and tenderness are caused, may be of 
service to diminish the subsequent stiffness and hasten its disappear- 
ance, and in all it may be useful to change every day or two the angle 
at which the limb is immobilized. 

LATERAL DISLOCATIONS OF THE FOREARM. 

Both bones of the forearm may be together dislocated to the inner 
or to the outer side, and the dislocation may be complete or incom- 
plete. In the incomplete form, in the sense in which the term has 
been generally, and will here be, used, one of the two bones still 
remains below or in front of the lower end of the humerus, although 
it may have entirely left its own corresponding articular surface ; thus, 
in the incomplete outward dislocation the sigmoid cavity of the ulna 
lies below and embraces the external condyle, and its inner slope may 
still correspond to the outer part of the trochlea or may have passed 
entirely to its outer side. In the complete outward dislocation, on the 



LATERAL DISLOCATIONS OF THE ELBOW. 649 

other baud, the sigmoid cavity of the ulna is turned toward (pronation) 
and embraces the outer side of the external condyle or the supinator 
ridge, and the head of the radius lies nearer the median line in front 
of the humerus. Much confusion has arisen from the use of the terms 
outward and inward dislocation to include also the outward and back- 
ward and the inward and backward respectively, both in text-books 
and in the reports of cases in the journals. The terms will be here 
restricted to those cases in which the primary dislocation is directly 
outward or inward, the coronoid process remaining in front of, and the 
olecranon behind, the transverse longitudinal (frontal) plane of the 
humerus. In some cases of outward and backward dislocation the 
question may arise whether the position in which the bones are found 
is not the result of a consecutive displacement following a primary 
outward displacement. I believe such consecutive displacements to be 
very rare, and that the great majority of backward and outward dis- 
locations belong, by their essential features, among the backward ones 
with which I have above described them. 

In a dislocation backward and inward this question does not arise, 
for a complete inward dislocation has never yet been reported ; but the 
confusion is, nevertheless, equally great, for the epithet " backward 
and inward " has been indiscriminately applied to all displacements 
toward the inner side, including, as Trelat pointed out, three distinct 
varieties : 1st, dislocations of both bones inward ; 2d, dislocations of 
both bones backward and inward, and 3d, dislocations backward of the 
ulna alone. 

Incomplete Lateral Dislocations. 

Doubtless it must be attributed to this confusion in the use of terms 
that the frequency of incomplete dislocations to the outer or the inner 
side passed unnoticed until 1863, when a German surgeon, Hahn, who 
had practised for more than forty years at Stuttgart, published a paper l 
upon the subject in which he stated that he had treated 21 cases of this 
injury in thirty years, nearly as many as those of dislocation back- 
ward observed during the same period ; of these 18 were in children, 
3 in adults; 12 of the former and 2 of the latter were in males, and 
in all but one the dislocation was inward. The statement, which was 
supported in many points by the observations of the reviewer of the 
paper, Streubel, at once attracted attention and has been confirmed and 
accepted by subsequent writers; the principal contributions to the sub- 
ject have been made by Hueter, 2 Nicoladoni, 3 and Sprengel. 4 Hueter 
described 6 specimens of outward dislocation obtained by resection and 
3 cases observed clinically ; Nicoladoni found 4 incomplete outward 
dislocations in 16 dislocations of the elbow observed in four and a half 
years ; and Sprengel reported that the records of the Halle clinic for 
the years 1873-1879 contained 32 cases, of which 20 were inward and 
12 outward. An important feature of the last communication is that 
15 of the 32 (11 inward, 4 outward) were old cases, and in only 1 of 

1 Hahn: Schmidt's JahrMcher, vol. exix. p. 74, and vol. cxx. p. SS. 

2 Hueter: Arch, fur klin. Chirurgie, 1867, vol. viii. p. IT);?, and vol. ix. p. 935. 

3 Nicoladoni : Wiener ined. Woehenschrift, 187G, pp. 570, 599. 640, and 670. 
* Sprengel : Centralblatt fur Chirurgie, 1880, p. 129. 



650 DISLOCATIONS. 

them could reduction be obtained. Although it is not so stated, it is 
probable that in many of them an error in diagnosis had been com- 
mitted ; Hahn says the injury is frequently mistaken for fracture of 
the lower end of the humerus. In a case seven months old reported 
by Sprengel the injury had been pronounced by a well-known London 
surgeon, who gave the patient a written opinion, an intercondyloid 
fracture of the humerus, and he added that there was no trace of the 
dislocation said to have existed ; Sprengel excised the joint and demon- 
strated the dislocation. On the other hand, Krbnlein's 94 cases (p. 
430) contain no examples, and in my experience they are relatively 
very few. 

The cause is usually a fall upon the outstretched hand ; exceptional 
causes are falls upon the inner side of the elbow and blows received 
upon the forearm. The interlocking of the central ridge of the sig- 
moid cavity in the groove of the trochlea is such that direct lateral 
displacement without preliminary separation of the articular surfaces, 
or without their fracture, is impossible, and it is highly probable 
that the dislocation is produced by abduction of the completely ex- 
tended forearm, or possibly by its equivalent pronation when partly 
flexed — that is, the ulna is moved downward (in the prolongation of 
the frontal plane of the humerus) and outward, turning upon the 
humero-radial articulation as a centre, and thus the internal lateral 
ligament is ruptured. The joint is thus opened upon its inner side, 
the sigmoid cavity and trochlea separated from each other, and only 
the radius and capitellurn remain in contact at their outer borders. If 
now the capitellurn slips inward along the upper surface of the radius 
an incomplete outward dislocation is produced ; if, on the contrary, the 
radius slips inward along the capitellurn an incomplete inward disloca- 
tion is the result. This mechanism can be reproduced upon the cadaver, 
but it must be admitted that the explanation is theoretical ; accurate 
clinical observations, for reasons often above referred to, are not obtain- 
able, and it is impossible to reproduce all the factors upon the cadaver. 

A. Incomplete Inward Dislocations. 

Pathology. The autopsies and direct examinations that have been 
reported and are available to show the new relations of the bones are 
few in number. There are two autopsies reported by Broca 1 and 
Jolivet, 2 and the case above referred to in which Sprengel excised the 
joint seven months after the injury was received. In the latter the 
head of the radius rested against the lateral part of the trochlea, and 
the ulna was displaced so far inward that nearly half of the sigmoid 
cavity projected free beyond the trochlea ; upon this free part, and 
united with it, lay the fractured tip of the epitrochlea. There was 
close fibrous union between the opposing surfaces. 

Broca's case was a much older one ; the specimen and a plaster cast 
of the limb are preserved in the Musee Dupuytren. It differs from 
the usual clinical form in the very marked displacement downward 

1 Broca : Bull, de la Soc. Anatomique, 1849, p. 272. 

2 Jolivet: Bull. de. la Soc Anatomique, 1866, p. 184. 



LATERAL DISLOCATIONS OF THE ELBOW. 651 

and backward of the head of the radius. The new joint permitted full 
flexion and almost complete extension, and the axis of the forearm was 
inclined downward and outward 30 degrees from the prolongation of 
that of the humerus. The distance between the prominences formed 
by the tip of the olecranon and the head of the radius was six centi- 
metres. There remained no trace of the lateral and annular ligaments ; a 
fibrous capsule of new formation connected the bones with one another. 
Broca says there was no sign of former fracture, but Denuce/ who ap- 
pears to have examined the specimen, says the external condyle appears 
to have been broken off and displaced forward. The sigmoid cavity 
embraces the epitrochlea, and forms a new articulation with it ; the 
radius lies below the inner part of the trochlea and projects notably be- 
hind it. 

Jolivet's specimen was obtained by amputation eighteen months after 
the injury. The elbow was flexed, the forearm semipronated, and 
there was very slight mobility. The olecranon, displaced inward, 
embraced the epitrochlea by its sigmoid cavity and projected beyond 
its inner side. The olecranon fossa was empty ; the anterior and inner 
part of the head of the radius rested upon the outer articular half of 
the trochlea, the sharp inner border of the latter lying like a wedge 
between the radius and ulna. The coronoid process lay in a new 
groove formed at the expense of the epitrochlea and the adjoining side 
of the trochlea. The posterior edge of the head of the radius could 
be felt as a prominence at the back of the joint. 

Both lateral ligaments are necessarily torn ; the annular ligament 
may perhaps resist, though it must at least be put upon the stretch by 
the interposition of the inner anterior edge of the trochlea between 
the head of the radius and the coronoid process. The clinical features 
indicate that the head of the radius lies rather below than directly in 
front of the trochlea, even in flexion of the elbow at a right angle. 

Symptoms. The axis of the forearm is parallel with that of the 
arm and a little to its inner side. The prominence of the epitrochlea 
is lost, that of the outer epicondyle increased. Flexion and extension 
are quite free, and painless within certain limits. 

On palpation, the olecranon can be recognized immediately behind 
the position of the epitrochlea and extending so far to the inner side 
as to mask this prominence completely ; the triceps shows as a rather 
prominent elevation running downward and inward. The external 
condyle can be plainly felt, and the absence of the head of the radius 
from its normal position recognized ; the latter can sometimes be felt 
below the empty olecranon fossa. 

Treatment. Reduction in recent cases appears to be easy by traction 
in the extended position and direct pressure upon the side of the ulna. 
Theoretically, outward lateral flexion combined with moderate traction 
and followed by direct pressure ought to effect reduction readily and 
without risk of fracture, especially if anaesthesia is employed. 

Sprengel's statistics, quoted above, indicate that reduction is very 
difficult in old cases; out of eleven only one was reduced, but the 

1 Denuce : Diet, de Med. et Chir. pratiques, art. Coude, p. 765. 



652 



DISLOCATIONS. 



length of time that had elapsed is not given except in the one case that 
was reduced, eight weeks. 

Broca's specimen and two of SprengePs cases show that the joint, 
even if reduction is not made, may have a free range of motion and 
the limb may be useful ; in his other cases SprengePs attempts to 
increase the range of motion failed more or less completely. 



Fig. 311. 



B. Incomplete Outward Dislocations. 

This form, although apparently somewhat less frequent than the pre- 
ceding, has been more fully studied. Its causes and mechanism have 
been described above. 

Pathology. Fig. 311 represents a specimen from an old case pre- 
sented to the Societe Anatomique by Poumet ; it is described by Mal- 
gaigne, Denuce, and Pingaud as one of the only two cases known, 
the other, PinePs, being very similar. The list has since been increased 
by the five specimens obtained by Hueter by resection, by Hutch- 
inson's autopsy, and by SprengePs case in which the dislocation be- 
came compound. A case which I reduced by 
arthrotomy three weeks after the accident 
belongs, I think, in this class, although the 
coronoid process lay behind the external 
condyle ; the epitrochlea lay in the groove of 
the trochlea, and a mass of new bone had 
formed on the back of the external condyle. 
The last three are the only examples of the 
condition in the recent state of which I have 
knowledge, and the information furnished by 
SprengePs relates only to the position of the 
bones. 

SprengePs 1 patient was a girl seven years 
old ; the injury was caused by a fall, was sup- 
posed to be a fracture, and was treated by 
immobilization in a gypsum dressing. Five 
weeks later she came under SprengePs obser- 
vation. On removal of the dressing a slough 
an inch in diameter was found to have formed, 
and through the opening created by it the in- 
ternal condyle presented. The head of the 
radius could be distinctly felt below the external condyle, the ulna 
was displaced outward so that the outer half of the sigmoid cavity 
embraced the capitellum ; the forearm was pronated and fixed in a 
position midway between flexion and extension. Forcible abduction 
was made as a preliminary to reduction, and the opening of the slough 
was thereby so enlarged that the position of the bones as described 
was verified by direct inspection. The child made a good recovery. 

Hutchinson's 2 specimen was of a recent case, the patient having 
died of associated injuries. The dislocation had been reduced during 




Old incomplete outward dis- 
location. (Poumet.) 



1 Sprengel : Loc. cit. 

2 Hutchinson : Medical Times and Gazette, 1866, vol. i. p. 410. 



OUTWARD DISLOCATIONS OF THE ELBOW. 653 

life ; on the table it could be easily reproduced, and the bones could 
be dislocated to either the outer or the inner side. The sigmoid notch 
rested against the external condyle and the head of the radius pro- 
jected beyond the latter. The lateral ligaments were completely torn, 
and there were several rents in the anterior one ; the orbicular liga- 
ment was entire, but much stretched. Small portions of cartilage had 
been broken from the articular surfaces of all three bones. 

Poumet's specimen (Fig. 311) is thus described by Pingaud. 1 "The 
ulna, carried directly outward, has completely left the trochlea, which 
projects on the inner side and contains in its groove a large sesamoid 
bone [evidently the broken-off epitrochlea, vide infra]. The external 
articular slope of the sigmoid cavity is in relation with the capitellum, 
which is notably hypertrophied, as is also the epicondyle, while the 
trochlea and epitrochlea are atrophied. The radius, displaced outward 
and especially forward, is in indirect relations with the epicondyle and 
the remainder of the condyle, outside of which is a small sesamoid 
bone which completes the surface of articulation on this side. It 
results from these anatomical relations that the forearm is in slight 
flexion with rotation inward ; the ligaments, especially the lateral ones, 
are in great part ruptured. 

Hueter's six specimens all showed the same displacement, and the 
epitrochlea torn off and lodged in the groove of the trochlea. The 
same avulsion of the epitrochlea was found in my case and clinically 
in seven others, Albert and von Dumreicher 2 each one, Hueter 3 three, 
and Eversham 4 two, in two of which it prevented reduction, and in 
the others made reduction very difficult. In two other cases, also 
observed clinically by Nicoladoni, in which reduction was not attempted 
because of the length of time that had passed since the injury was 
received, fourteen and five months respectively, the epitrochlea was 
broken oif ; in one it could not be found, in the other it lay below and 
near the sharp inner edge of the trochlea. 

Nicoladoni, after experimenting upon the cadaver, reached the opin- 
ion, which seems to be correct, that this avulsion of the epitrochlea is 
effected through the attached flexor muscles and not through the inter- 
nal lateral ligament which is inserted only upon its base. 

His experiments show that the internal lateral ligament is always 
ruptured, usually close to its insertion at the base of the epitrochlea, 
but sometimes nearer to or at its attachment to the ulna. The rupture 
extends backward along the margin of the sigmoid cavity to the tip 
of the olecranon, and in front through the anterior ligament to the 
outer side of the coronoid process. The external lateral and the 
annular ligaments are untorn. The clinical cases indicate, however, 
that the annular ligament also is sometimes ruptured. 

Symptoms. The elbow is somewhat flexed, the angle varying in the 
different cases, the forearm pronated. The axis of the forearm is 
sometimes parallel with and external to that of the arm, sometimes 
adducted. The prominence of the internal condyle is increased, and 

1 Pingaud: Loc. eit., p. 52(5. 

2 Nicoladoni: Loc. eit., p. 571. 

:! Heuter : Arch, fur klin. Chir., vol. ix. p. 935. 
l Eversham: Deutsche Zeitsehrift fur Chir., vol. Ix. p. 528, 



654 DISLOCATIONS. 

the skin is tightly stretched over it. The trims verse diameter of the 
elbow is increased by the projection of the muscles and the head of 
the radius on the outer side. Flexion and extension are painful and 
restricted. In the reported cases no mention is made of lateral 
mobility. 

On palpation the epitrochlea, unless broken off, is very readily felt ; 
if it is broken off, the inner side and edge of the trochlea can be 
plainly traced, and the epitrochlea may perhaps be recognized as a 
movable body below it, or it may have been drawn past the edge of 
the trochlea into its groove where it cannot be felt. 

On the outer side the head of the radius projects in a line with the 
anterior or under surface of the condyle, according as the elbow is 
more or less flexed. The olecranon is more prominent than normal, 
because it is lifted out of its fossa and lies against the back of the 
more prominent external condyle ; it is distant from the epitrochlea about 
two inches. The triceps appears as a prominent cord directed down- 
ward and outward to the olecranon. The external epicondyle may be 
felt by pressing the finger firmly in above the head of the radius and 
behind the prominence formed by the extensor muscles of the hand. 

According to Pingaud, the forearm is so pronated that the posterior 
surface of the ulna looks outward, and the head of the radius lies in 
front of the capitellum instead of being displaced outwardly. Such 
cases belong, I think, to the class of dislocations of the ulna alone. 

Treatment. The first indication of treatment is to lift the central 
ridge of the sigmoid cavity and the coronoid process out of the groove 
between the capitellum and the trochlea, or, in other words, to separate 
this portion of the ulna sufficiently from the under surface of the 
humerus to allow it to be pushed inward past the projecting outer 
border of the trochlea. This may be effected by hyperextension, or 
by outward lateral flexion if the head of the radius still rests against 
the under surface of the humerus so as to form a fulcrum or centre for 
the movement. 

If hyperextension is made, the movement takes place about the tip 
of the olecranon as a centre, where it rests against the back of the 
humerus, and the coronoid process is carried downward away from the 
humerus as well as backward, and when the separation is sufficient 
direct pressure with the thumbs upon the head of the radius will force 
the bones into place, or rotation of the ulna inward (supination) will 
carry the tip of the coronoid process past the margin of the trochlea 
into the groove. Xicoladoni suggests that in the latter manoeuvre an 
assistant should press with his thumb upon the back of the olecranon 
to prevent the production of a backward dislocation. 

Outward lateral flexion should be aided by traction upon the extended 
or slightly flexed forearm, by which the articular surfaces will be sepa- 
rated as far as the untorn ligaments will permit, then pressure by the 
thumb upon the head of the radius will force the inner ends of the 
bones back into line, and the straightening of the limb completes the 
reduction. 

If the annular ligament is torn, its outer portion and the adjoining 
part of the external lateral ligament may be interposed between the 



OUTWARD DISLOCATIONS OF THE ELBOW. 655 

radius and the humerus and oppose the return of the former • under 
such circumstances the ulna can still be reduced, but the lateral press- 
ure to effect this must be made upon the olecranon instead of the 
radius, and then by pronating and adducting the forearm the radius is 
drawn past the obstacle into place. The suggestion of the existence 
of this obstacle and of the means by which it may be avoided rests 
entirely upon experiments on the cadaver. *I do not know that it has 
ever been encountered and thus overcome in practice. 

The complication of avulsion of the epitrochlea and its lodgement 
in the groove of the trochlea seriously increases the difficulty of reduc- 
tion. As above stated, in two of the five recent cases in which it was 
recognized reduction failed. The reason of the failure is that the dis- 
placement of the fragment from the groove by the returning ulna is 
prevented by the sharply inclined inner slope of the trochlea and by 
the pressure of the overlying muscles and fascia. The fragment needs 
to be drawn downward as well as pushed inward. Albert succeeded 
by flexing the forearm at a right angle, and then drawing it forcibly 
away from the humerus in the direction of the long axis of the latter 
by means of a cord passed across its anterior surface close to the 
elbow. The same method, when employed by von Dumreicher, failed, 
as did also forcible outward lateral flexion and traction, although car- 
ried so far as to threaten rupture of the skin on the inner side of the 
joint. 

Possibly the transformation of the dislocation into the direct back- 
ward form, or backward and inward, would remove the fragment from 
the groove and make reduction possible, or it might be practicable to 
draw the fragment downward out of the way by a sharp hook passed 
through the skin. Other means failing, the obstacle could be easily 
reached and removed through an incision on the inner side. 

Complete Dislocations Outward. 

These dislocations, of which the first observation was reported by 
Dupuytren in 1807, although the form had been described by Petit 
nearly one hundred years before, were apparently so rare that Mal- 
gaigne could collect only ten reported cases. Of late, reports have so 
multiplied that, excluding irregular cases, and those of which the 
description is not sufficiently detailed, and those which seem more 
properly to belong among the dislocations backward and outward, the 
number of those available for study and generalization is about twenty- 
five. 1 

1 The bibliography, excluding doubtful cases, is as follows : Dupuytren, Lecons orales, 
vol. i. p. 131 ; Bouley, Bull, de la Soc. Anatornique, 1837, p. 101; Nelaton, Pathol, chirur- 
gicale, vol. ii. p. 391 ; Neilson, Lancet, 1844, ii. p. 559: Bobert, Gaz. des Hopitaux. 1849, 
p. 180 ; Soule, Gaz. Medicale, 1849, p. 717 ; Verneuil and Triquet, Gaz. Medicale, 1851 [?] ; 
Piogey and Dubrueil, Gaz. des Hopitaux, 1851, p. 30 ; Denuce, These de Paris. 1853 : Flau- 
bert, idem ; Puech, Gaz. des Hopitaux, 1859, p. 434 ; Sistach, Bull, de la Soc. deChirurgie, 
1866, p. 520; Varick, New York Medical Record, 1867, vol. ii. p. 387 ; Andrews, idem, 
1875, p. 720; Von Pitha, Pitha and Billroth's Chirurgie. vol. iv.. abt. 2. B. p. 71. -1 cases ; 
Hatry, Lyon Medical, 1876, vol. xviii. p. 13; Wylie, in Hamilton's Fractures ami Dislo- 
cations, p. 698; Bertin, Union Mod., 187(5. p. 609; Osborne. New York Hospital Gazette, 
1879, p. 613; Mason, New York Medical Record. 1880, vol. xvii. p. 397, 2 cases; Towne, 
idem, p. 525 ; Ekwurzel, Philadelphia Medical and Surgical Reporter. 1881. vol. xlv. p. 



656 DISLOCATIONS. 

In most of the cases the mechanism of production cannot be deter- 
mined, but the histories of a few are sufficiently complete to show that 
the cause may be a fall upon the outstretched palm or upon the elbow, 
or a blow received upon the inner side of the forearm. Hatry's case 
is a clear example of the first, the patient stumbled and fell forward 
upon his hand ; von Pitha's patient, who fell while her hands were in 
her muff, is an example of the second ; and Mears's patient, who was 
struck upon the inner and upper part of the forearm by a revolving 
piece of wood while the elbow was partly flexed in an effort to draw 
down some object from above his head, is an example of the third. The 
mechanism in a fall upon the hand is doubtless the same as that in 
incomplete dislocation outward produced in the same manner — that is. 
outward lateral flexion is produced ; the internal lateral ligament is 
ruptured, and then the bones are displaced laterally past one another 
by the continued action of the weight of the body. In one of von 
Pitha's cases this lateral flexion was observed by the mother of the 
patient, a boy, six years old, who saw the elbow bend as he fell from 
a tree upon his outstretched hand. 

Pathology. The only recorded autopsies are those of Bouley and 
Heinlein ; in the former, a compound dislocation with fracture of the 
external condyle produced by a fall upon the elbow from a height of 
twenty-eight feet, amputation was refused, and the patient died on the 
twenty-fifth day. The lateral ligaments of the elbow were entirely 
ruptured ; both bones of the forearm were placed externally to the 
lower extremity of the humerus, and the ulnar nerve was lacerated at 
the level of the trochlea. In the latter both lateral and the anterior 
ligaments were torn, the radial nerve bruised ; a fragment was broken 
from the head of the radius, and the coronoid process was broken. 
The radius and ulna were also broken near the middle. 

Disregarding one or two exceptional forms, the cases may be grouped 
in three classes according to the character of the displacement, but in 
some the account is not sufficiently complete to determine to which 
class the case should belong. In one, apparently the least frequent, 
the displacement is directly outward and a little upward, so that the 
inner edge of the sigmoid cavity rests against the outer surface of the 
external condyle, the elbow being partly flexed, with the olecranon 
behind and the coronoid process in front of the epicondyle. The 
radius preserves its relations with the ulna and is situated still further 
to the outer side, or is carried to a somewhat higher level by pronation 
of the forearm. This involves complete rupture of the lateral and an- 
terior ligaments. In Neilson's case it was thought the external condyle 
was broken ; the olecranon was three inches above its usual position. 

In the second class the forearm is pronated as well as flexed, and 
this pronation is effected by rotation about the long axis of the ulna, 
so that the head of the radius lies above, or even further inward than, 

38; Mears, Philadelphia Medical Times, 1880-1, vol. xi. p. 89; Johnson, Transactions of 
the Missouri State Medical Association, 1880, p. 33: Battiscombe, Lancet, 1886, ii. p. 
397; Heinlein, Centbl. fur Chir., February 1,1890; Stimson, here given; Winslow, 
Annals of Surgery, May, 1900, p. 595. I have not been able to verify the reference 
for Dupuytren's and Verneuil's cases. The Gazette Medicale for 1851 does not con- 
tain the latter; in the Gazette des Hopitaux, 1851, pp. 93 and 201, is an article by 
Verneuil and Triquet which contains a case of incomplete outward dislocation. 



OUTWARD DISLOCATIONS OF THE ELBOW. 657 

the ulna. The great sigmoid cavity embraces the outer surface of the 
external condyle, the tip of the olecranon lying behind the condyle 
and that of the coronoid process in front of it. The anterior surface 
of the ulna looks inward. The head of the radius lies above its nor- 
mal position, in front of the humerus, and possibly still in contact with 
the upper part of the articular surface of the capitellum. Study of 
the skeleton indicates that this form can be easily produced from an 
incomplete outward dislocation by pronation of the limb ; it is, I think, 
the most common of the three classes, and it seems possible that the 
external lateral ligament may be preserved untorn. Denuce has given 
it the name of sub-epicondylar, in distinction from the following, third 
class, which he terms supra-epicondylar. He thinks the distinction is 
an important one and that the difference depends upon the rupture or 
the integrity of the attachment of the muscles upon the epicondyle. 

In the third class the ulna and radius, pronated and flexed, are car- 
ried higher up along the outer border of the humerus, two inches in 
Osborne's case. The sigmoid cavity may embrace the supinator ridge, 
and the radius still lie in front of the humerus, or both bones may be 
displaced also backward so that the coronoid process and the articular 
surface of the radius are posterior to the ridge. 

It is noteworthy that in none of the cases is fracture of the epi- 
trochlea mentioned ; in one or two it is said that the epitrochlear 
muscles were torn away at their insertion. 

Two cases, in which an additional consecutive displacement had fol- 
lowed by which both bones were brought around in front of the 
humerus and pronated so far that their posterior surfaces were directed 
forward, were reported by Cloquet 1 and Maisonneuve. 2 The latter's 
patient Avas a woman who had fallen out of bed upon her elbow, and 
who was so thin that the position of the bones could be accurately 
determined ; the lower end of the humerus projected prominently 
behind and was there covered only by the skin, while the triceps 
ran forward and outward over the epicondyle. The ulna was com- 
pletely turned around so that its posterior surface looked forward and 
the sigmoid cavity lay against the front of the trochlea. The head 
of the radius could not be felt. The limb was slightly flexed and 
greatly pronated. Reduction was effected by moving the olecranon 
outward and backward around the external condyle to the back of the 
humerus, and then reducing in the usual manner the backward disloca- 
tion thus produced. 

Symptoms. Of the first variety, dislocation directly outward, with- 
out rotation of the forearm (Fig. 312), Puech's case may be taken as 
a type. The patient was a man forty-one years old, and the injury 
was caused by a fall from a height of about two feet, the elbow striking 
against some stones. The forearm was extended and supinated ; ir 
could be passively flexed nearly to a right angle, but could not be pro- 
nated; its axis lay entirely to the outside of the humerus, and the 
transverse diameter of the elbow was nearly doubled. Tracing the 
bones with the finger behind, from the epitrochlea outward, the sur- 

1 Cloquet: Quoted by Malgaigne, loc. oit., p. 616. 
- Maisouueuve : Gaz. des Hopitaux, 1S67, p. 115. 



(558 



DISLOCATIONS, 



geon recognized all the points of the lower end of the humerus, then 
the olecranon well above and to the outer side of the condyle, and then 



Fig 312. 



Fig. 313. 





Complete outward dislocation. 
(Denuce.) 



Complete outward dislocation of the elbow. Supra- 
epicondylar. (Stimson.) 

the head of the radius lower than the 
olecranon but still above the lower 
line of the humerus. In other similar 
cases extreme mobility of the joint is 
mentioned; as if the two segments, of 
the limb were very loosely attached to 
each other. 

In the second variety, " sub-epi- 
condylar" the axis of the forearm 
appears generally to be inclined downward and inward (adduction) ; 
flexion at, or even within (Pitha), a right angle is common ; semi-pro- 
nation or full pronation. The transverse diameter of the elbow is 
increased, but not so much as in the preceding variety. The supinator 
and radial extensor muscles form a well-defined prominence above and 
in front of the joint ; the tendon of the triceps shows as a prominence 
directed downward and outward, and the tendon of the biceps can 
sometimes be felt running in the same direction in front. 

The outlines of the lower end of the humerus can be distinctly 
traced from the epitrochlea outward to the capitellum ; the external 
epicondyle is masked by the ulna, but sometimes can be felt by press- 
ing the finger deeply in above the latter. The cup-shaped surface of 
the head of the radius can be felt unless it has been carried so far 
inward by the pronation of the limb that it rests against the front of 
the humerus. 

In the third variety, " supra-epicondi/lar" (Fig. 313), the forearm 
is flexed at, or nearly at, a right angle and pronated ; the transverse 
diameter at the lower part of the arm is increased. The greater the 
displacement upward, the greater is the passive mobility of the limb 
in the plane of flexion and extension. The lower end of the humerus 



FORWARD DISLOCATIONS OF THE ELBOW. 659 

is accessible to the touch even more completely than in the two preced- 
ing varieties, for it projects completely below, and even its external 
condyle can be traced. The deformity on the outer side varies with 
the extent and character of the final displacement, for the bones of the 
forearm are sometimes carried backward, crossing the humerus, or, as 
in Maisonneuve's and Cloquet's cases, carried forward to the front of 
the humerus. 

It is noteworthy that in three of the four cases in which reduction 
was not made the patients had good control of the limb and a free 
range of motion was established. Wylie's patient thought his arm 
was as serviceable as ever. Robert's patient was seventy years old 
and his injury dated from infancy ; he had an extensive range of 
flexion and extension. In Denuce's case (Fig. 312) the olecranon 
projected nearly an inch behind the humerus, the arm could be fully 
extended and flexed nearly to a right angle. In Nelaton's case there 
was flexion nearly at a right angle. 

It is also noteworthy that in no case were there symptoms of inter- 
ference with the circulation, and in only one case (Mears) were there 
symptoms of injury to the nerves. In his there were pain in the fingers 
and numbness in the distribution of the median nerve. 

Treatment. Reduction has been effected without difficulty in all the 
recent cases, except Winslow's, by extension and direct manipulation of 
the upper ends of the radius and ulna. The laceration of the ligaments 
and muscles is so great that the bones are freely movable, and special 
manoeuvres intended to relax opposing bands are seldom necessary. Ex- 
ceptions to this may be found sometimes in the first and second varieties ; 
in the first the head of the radius may pass through and be caught, as 
apparently happened in Puech's case, between two muscular bundles, 
which may then need to be relaxed by flexing and abducting the fore- 
arm ; in the second, which appears sometimes, as has been said, to 
differ from the incomplete outward dislocations only in the addition of 
pronation of the forearm, the external lateral ligament remaining 
untorn, the first movement must be to supinate the limb and thus turn 
the sigmoid cavity under the capitellum and bring the head of the 
radius to the outer side ; the dislocation is then an incomplete outward 
one, and is reduced accordingly. In a case in which previous attempts 
by traction in extension under anaesthesia by other surgeons had failed 
I reduced easily by flexing the elbow at a right angle and pressing 
the head of the radius downward and around the lower outer edge of 
the condyle. 

DISLOCATIONS OF THE FOREARM FORWARD. 

Although mentioned by Hippocrates and characterized by him as the 
most painful of all and fatal in a few days, and admitted by all sub- 
sequent writers, the first recorded case (and that a questionable one) oi 
this dislocation was published only a hundred years ago. and the num- 
ber has not yet reached twenty-five, even including seven eases in 
which the olecranon was broken off and remained in place. 1 

1 The bibliography is as follows: Evers, Monin, Ckiyot, Wittlini>vi\ quoted by St reubel 
in Prager Vierteljahrschrift, 1850, ii. p. 37, and by Malgaigne, loo. eit., p. 626; Guerre, 



660 DISLOCATIONS. 

Of the 13 cases in which the age is mentioned, 1 was six years old, 
2 were eight, 2 fourteen, 2 fifteen, and 1 each eighteen, twenty, thirty- 
four, thirty -eight, and forty years old, 1 was an "adult," and 1 
" middle aged." The cause in the greater number of cases appears to 
have been a fall upon the flexed elbow ; in one (Pryor) it was a blow 
by the handle of a crane upon the back of the elbow ; in two certainly 
(Date, Ray), and probably in others, it was a fall upon the palm of the 
hand ; in Fulton's it was traction on the extended arm, without frac- 
ture of the olecranon ; in one (Caussin) the patient's hand was caught 
between two cogwheels and both bones of the forearm were broken at 
the middle as well as dislocated ; and in one (Morel-Lavallee) the 
patient fell from a wagon and was run over, the wheel passing across 
the elbow and breaking the olecranon and coronoid process. 

In seven of the cases the olecranon was broken, and in these the 
mechanism of the dislocation is easily understood, for, the resistance 
of the olecranon being removed, the two bones can be easily displaced 
forward and upward along the front of the humerus by a force acting 
upon the back of the forearm. Such cases, I think, should hardly be 
put in this class ; the dislocation is secondary to, and made possible by, 
the fracture of the olecranon. A personal case of this kind is shown 
in Plate XVII. I have recently (1899) seen another. In the case of a 
fall or of a blow upon the flexed elbow the direction of the force is 
probably inclined somewhat away from the axis of the forearm and is 
more nearly parallel with the posterior portion of the articular surface 
of the olecranon, and it must be great enough to rupture the lateral 
ligaments without the aid of leverage. All attempts to reproduce the 
dislocation upon the cadaver by this mechanism, forced flexion and 
direct impulsion, have failed, except after preliminary division of the 
lateral ligaments. 

In the case of a fall upon the hand there is clinical evidence to show 
that this form is closely allied to the lateral dislocations, and that it is 
produced by lateral outward flexion supplemented by sufficient torsion 
(supination) of the limb to bring the olecranon forward under the 
trochlea; in several cases the displacement was outward as well as for- 
ward ; in Chapel's, so far outward that the case has been classed with 
the lateral dislocations. 

Pathology. One autopsy (Richet), three amputations (Canton, Morel- 
Lavallee, Rigaud), two compound fractures of the olecranon without 
amputation (Richet, Guerre), one compound dislocation without frac- 

quoted by Pingaud in Diet. Encyclopedique, 1st ser., vol. xxi. p. 708 ; Chapel, quoted by 
Malgaigne, loc. cit., p. 617, as a dislocation outward ; Colson, Leva, quoted by Debruyn 
in Annales de la Chirurgie Francaise et Etrangere, 1843, vol. ix. pp. 44 and 45, and by 
Streubel; Eichet, Archives generales, 1839, vol. vi. p. 472; Prior, Lancet, 1844, ii. p. 366; 
Ancelon, L'Union Medicale, 1859, vol. iii. p. 394; Canton, Dublin Medical Journal, 1860, 
ii. p. 24 ; Secrestan, Gazette des Hopitaux, 1860, p. 598 ; Caussin, L'Union Medicale, 1861, 
vol. xi. p. 475, and Bulletins de la Societe de Cbirurgie, 1861, vol. ii. p. 451 ; Eichet, Bull, 
de la Soc. de Chirurgie, 1859, vol. ix. p. 110 ; Morel-Lavallee, idem, p. 107 ; Greenaway, 
quoted by Hutchinson, Medical Times and Gazette, 1866, i. p. 409; Langmore, Lancet, 
abstract in New York Medical Eecord, 1867, vol. ii. p. 10 ; Eigaud, Bulletins de la Societe 
Anatomique, 1870, p. 15; Date, Lancet, 1872, ii. p. 597; Mons, Deutsche Mil. Zeitschrift, 
1877, p. 401 ; quoted by Poinsot, loc. cit., p. 951 ; Kronlein, Deutsche Chirurgie, Lief. 26, 
p. 30 : Stimson, see Plate XIII. ; Eav, quoted bv Piatt, Fractures and Dislocations of 
Upper Extremity, 1899, p. 200; Fulton, Med. Eecord. 1897, vol. Iii. p. 738 ; Staunton, Brit. 
Med. Journ., 1905. Dec. 9, p. 1520. Eeferences have also been made to a case by Ferguson, 
Surgery, 3d ed., p. 241, one by Eoser, Chirurg. Anat., 1844, p. 477, and one by Flaubert. 



FORWARD DISLOCATIONS OF THE ELBOW. 661 

tare (Prior),~and experiments upon the cadaver show how great the 
laceration sometimes is. In Prior's case, in which the patient was 
struck upon the " under side of the left arm at the elbow-joint " by 
the rapidly-revolving handle of a crane, there was a large wound at the 
point where the blow was received, " occasioning a general disconnec- 
tion of its parts, muscular and otherwise, excepting immediately in 
front." The radius and ulna were driven upward and forward on the 
humerus ; the condyles of the latter and its shaft for two and a half 
or three inches projected through the wound nearly at right angles 
with the forearm, as completely stripped as if cleaned with a knife. 
There was no fracture. Reduction was made ; the patient recovered 
after much suppuration in and around the joint, and the final result 
was good, "the limb gaining in freedom and power." 

In Canton's case, the patient, a man forty years old, was thrown 
from a wagon ; apparently he struck upon the extended hand, but the 
forearm was immediately flexed and twisted under his chest. The 
forearm was flexed, the hand supinated, the swelling very great, and 
the skin tense and threatening to slough over the internal condyle. The 
antero-posterior and lateral diameters of the joint were increased, and 
the head of the radius could be indistinctly felt externally and ante- 
riorly. The diagnosis was not made, and "attempts to correct the 
maladjustment " failed ; after a delay of forty-eight hours, during 
which the swelling increased and sloughing was established, amputa- 
tion well above the condyles was resorted to. 

Examination of the limb showed (Fig. 314) that the upper surface 
of the olecranon rested against the front of the capitellum ; the annular 
and interosseous ligaments were whole, the anterior ligament w r as rup- 
tured except in its centre, the posterior 
and both lateral ligaments ruptured. The FlG - 314 - 

triceps was completely detached from the 
olecranon. The two radial extensor muscles 
and all the muscles arising from the epicon- 
dyle except the supinator brevis and the 
anconeus were detached, as was also the 
epitrochlear head of the flexor carpi ulnaris. 
The ulnar nerve was torn behind the con- 
dyle. The other large nerves and the main 
vessels were uninjured. 

Richet's first patient was eighteen years 
old and had fallen from a height of forty- 

n e mi r 1 • 1 l n i Forward dislocation ot the elbow : 

nve teet. I he forearm was slightly flexed cantons ease. 

and in supination, and was immovable ; 

it was shortened an inch, measuring from the epicondyles to the lower 
ends of the radius and ulna. The olecranon was in place and movable ; 
two inches below it was a large wound through which the lower end 
of this fragment projected. The head of the radius ami the broken 
end of the ulna were recognizable in the fold of the elbow a finger- 
breadth above the condyles. Reduction was easy by traction, bur re- 
currence at once followed. The patient died three hours later. The 
autopsy showed the annular ligament to be intact. 




662 DISLOCATIONS. 

In addition to these two varieties, dislocation with and without frac- 
ture of the olecranon, the difference between which is so important, 
there is another, based upon clinical and experimental evidence, to 
which the name incomplete is given ; in it the upper end of the olecra- 
non rests against the under and anterior surface of the humerus instead 
of passing upward in front of it. So far as can be inferred from the 
reported cases it is the most common form. The use of the terms first 
and second degree, to distinguish between the two forms, is, I think, 
to be preferred to that of incomplete and complete. 

In Chapel's case the additional outward dislocation, which is noted 
in several of the others, was so great that Malgaigne classes it with the 
outward dislocations. The patient was a boy fourteen years old. The 
radius formed a marked prominence under the skin on the outer side ; 
on its inner side could be felt the olecranon and its sigmoid cavity. 
The two bones overrode the humerus in front about two centimetres ; 
the epicondyle lay behind the ulna. Mons's case seems to me to be of 
the same kind. It is quoted by Poinsot as a unique example of diver- 
gent dislocation, ulna forward and radius outward. The description 
is limited to this statement and does not definitely exclude the possi- 
bility that the ulna may have been displaced outward as well as forward. 

Fracture of the epitrochlea has been observed in one case (Date's), a 
boy fourteen years old, and this is the one in which the evidence that 
the dislocation was produced by external lateral flexion in a fall upon 
the hand is most complete. The head of the radius was prominent 
outside of and below the outer condyle ; above it was a deep depression 
in which the condyle could be obscurely felt ; the olecranon was below 
its usual position, resting with its extreme end against the trochlea 
(first degree, or incomplete). The limb w T as semi-flexed. Reduction 
was easy under chloroform ; the radius first, and then the ulna, going 
back into place with a distinct snap. If this account of the positions 
of the two bones is accurate the annular ligament was probably torn. 

Symptoms. In five of the cases uncomplicated by fracture it is stated 
that the forearm was lengthened, more than an inch in one of them, 
and with this coincided a position of the limb which is mentioned in 
several others, namely, slight or partial flexion, which could generally 
be changed somewhat in either direction. In one in which the range 
of motion is specified (Langmore), the limb was held at an angle of 130 
degrees, could be flexed to a right angle and extended to 160 degrees; 
in another (Colson), hyperextension could be made without causing pain, 
and during the movement the olecranon passed forward between the 
biceps and pronator teres. 

In correspondence with this lengthening there is flattening of each 
side and of the back of the elbow, unless the swelling is sufficient to 
mask it, with prominence of the inner and sometimes of the outer con- 
dyle, and the formation of a transverse sulcus appreciable by the touch 
behind between the humerus and the olecranon. In one case the fore- 
arm was also abducted. In Canton's case the forearm was flexed 
beyond a right angle ; the olecranon rested against the capitellum, and 
the triceps was torn completely from it. It seems probable that detach- 
ment or rupture of the triceps is a necessary condition of the passage 
of the olecranon to any distance alon^ the front of the. humerus, and 



FORWARD DISLOCATIONS OF THE ELIIOW. (\l'>:\ 

that the existence or absence of the detachment may constitute the 
essential difference between the complete and incomplete forms, or the 
first and second degrees. The clinical features which differentiate the 
two forms are that in the lesser form the olecranon is prominent below 
the humerus when the elbow is flexed, and the forearm is lengthened 
when it is extended or but slightly flexed. In the second, " complete " 
form, the forearm is more or less shortened when extended, but is 
lengthened when flexed at or near a right angle, and its anteroposte- 
rior diameter is increased because of the projection of the coronoid 
process in the fold of the elbow. The biceps tendon can be recognized 
on the outer side of the latter, and beyond it the head of the radius. 
Posteriorly, in both forms, the olecranon fossa is empty ; the direction 
of the ulna also plainly indicates the change in the position of its 
upper end unless the swelling is great. 

Course and Prognosis. In only one case (Canton) did the dislocation 
remain unreduced, and, as in this the diagnosis was not made because 
of the swelling, there is reason to suppose that a suitable attempt 
to reduce would have been as successful as it proved in the others. 
It was also the only case, of those uncomplicated by a compound frac- 
ture of the olecranon, that did badly and in which amputation was 
thought to be necessary. The history of the case, moreover, suggests 
that the decision was reached rather hastily and on grounds that might 
be deemed insufficient. 

Of the 7 compound dislocations, of which 6 were complicated by 
fracture of the olecranon, 3 recovered, 2 underwent amputation after 
the joint had suppurated, 1 died three hours after the accident, which 
was a fall from a height of forty-eight feet, and in 1 (Kronlein) the 
result is unknown. Of the 3 recoveries, the joint suppurated in 2 
(Prior, Richet's second), the process ending in anchylosis in one of them ; 
in the remaining 1 the patient recovered apparently without suppura- 
tion, the fracture of the olecranon united by a fibrous band one centi- 
metre long, and two and a half months after the accident the hand 
could be brought to the mouth and the elbow extended to an angle of 
150 degrees. Whether antiseptic methods will improve this poor 
record remains to be seen. 

Treatment. In all the cases in which the olecranon rests against the 
lower part of the end of the humerus, the so-called incomplete dislo- 
cations, reduction has been easily effected by pressing or pulling the 
upper end of the forearm downward and backward, or by flexing the 
limb against the knee or the arm of an assistant placed in the fold of 
the elbow. In Greenaway's case the bones slipped into place almost 
spontaneously when the elbow Avas flexed. 

In the cases in which the bones are displaced further upward it is 
desirable to flex the limb within a right angle and then to pull the 
upper ends of the bones back into place by a strap passed around the 
front of the forearm close to the elbow. 

Dislocations complicated by compound fracture of the olecranon must 
be treated in accordance with the general principles o\' treatment oi' 
compound articular fractures, of which they are a severe form, severe 
because of the greater extent of the laceration of the soft parts. In 
my own case, simple fracture of the olecranon, seen about two months 



664 DISLOCATIONS. 

after the accident, I made reduction by an incision along the ulna 
which exposed the joint and the fracture. 

DIVERGENT DISLOCATIONS OF THE RADIUS AND ULNA. 

The characteristic feature of this form is that the radius and ulna 
do not accompany each other, but are displaced in divergent directions. 
Two varieties have been observed : the antero-posterior, in which the 
ulna passes up behind the humerus, and the radius passes up in front, 
and of which there are fourteen recorded cases ; x and the transverse, of 
which there are two cases, in which the divergence was mainly lateral, 
the olecranon passing to the inner side behind the epitrochlea, and the 
radius to the outer side. 2 Several authors make an additional variety, 
ulna backward, radius outward, on the basis of the case of Samuel 
White quoted by Cooper, 3 which seems to me to be a dislocation of 
both bones backward and outward ; and Poinsot makes a fourth variety 
of the case of Mons which I have placed among dislocations of both 
bones forward. 

A. Antero-posterior. 

Excluding Chevalier's case, of which I have no details, the thirteen 
patients were, with one exception (Tillaux), males, and with three 
exceptions, adults ; two were nine years old, one thirteen. The cause 
was usually a fail from a considerable height, or with violence, as from 
a moving railway car, a horse, or a wagon ; in one it was a fall while 
carrying a heavy timber, in another while wrestling ; and in Tillaux's 
the patient, while lighting a match, struck her elbow against a piece 
of furniture behind her ; the pain was so great that she fainted and 
fell to the floor, where she was found with her elbow abducted and 
flexed. Scott's patient was thrown from a horse, striking upon his 
head and hands ; he found his elbow dislocated and the forearm partly 
flexed ; a bystander pulled it straight, and he felt something give way 
in the joint, and a bone appeared to slip forward ; possibly a disloca- 
tion of the ulna alone backward was thereby transformed into the 
divergent one which was afterward recognized. Von Pitha's patient 
fell head foremost from the second story of a building upon a pile of 
planks between which the extended forearm was caught and held while 
the body was violently precipitated backward. 

Pingaud, experimenting upon the cadaver, found it easy to produce 

1 Bulley, Provincial Medical and Surgical Journal, 1841, quoted in the Gazette Medi- 
cale, 1841, p. 666; Michaux, quoted by Debruyn in Annales de Chir. Francaise et 
Etrangere, 1843, vol. ix. p. 52 ; Mayer, Gazette des Hopitaux, 1848, p. 232 ; Von Pitha, 
Pithaand Billroth's Chirurgie, 4th vol. 2d Abt. B. p. 78; Chevalier, Arch. Med. Beiges, 
October, 1870, quoted by Bardeleben, Chirurgie, vol. ii. p. 759 ; Gripat, Bull, de la Societe 
Anatomique, 1872, p. 176 ; Arnozan, Bordeaux Med., 1873, p. 402, quoted by Poinsot, loc. 
cit., p. 945 ; Tillaux, Gazette des Hopitaux, 1877, p. 786 ; Minich, Lo Sperimentale, 1880, 
quoted by Poinsot; Mason, New York Medical Eecord, 1880, vol. xvii. p. 397; Scott, 
Bristol Medico-Chirurgical Journal, March, 1886, p. 36; Duret, reported by Vanheu- 
verswyn, Journal des Sc. Med. de Lille, Sept. 9, 1892 ; Petzholdt, Arch, fur klin. Chir., 
1894, vol. xlix, p. 243; Ferguson, British Medical Journal, April 6, 1895, p. 753. 

Guersant, reported by Warmont in Bevue Medico-Chirurgicale, vol. xvi. p. 303, 
quoted by Pingaud in Diet. Eucyclopedique, art. Coude, p. 600, and by Poinsot; Wight, 
Physic, and Surgeon, Ann Arbor, February, 1893. 

3 Cooper: Dislocations and Fractures, American edition, p. 384. 

4 Pingaud : Loc. cit., p. 598. 



DIVERGENT DISLOCATIONS OF THE ELBOW. 665 

the dislocation by forced pronation of the forearm after division of 
the internal lateral ligament ; this fact, taken in connection with the 
fall upon the hand noted in several of the cases, indicates that the 
mechanism, in these cases at least, is a lateral outward flexion, by 
which the internal lateral ligament is ruptured, followed or accom- 
panied by forcible pronation, and then by the direct movement down- 
ward of the humerus between the two bones. Fracture of the epi- 
trochlea observed in one case (Arnozan) supports the theory of outward 
lateral flexion. In two cases (von Pitha, Gripat) the coronoid process 
was broken ; in both the fall was from a considerable height. 

The explanation of the mechanism in the two cases in which the 
injury was attributed to a fall upon the abducted and flexed elbow 
(Michaux and Tillaux) shares in the difficulty which attaches to the 
explanation of dislocation of both bones backward by the same cause. 
If the alleged rotation of the ulna backward and outward around the 
radius, by which the internal lateral ligament is torn, is accepted, it 
will not be difficult to conceive that the radius may remain in front ; 
but even this leaves unexplained the forcible descent of the humerus 
between the two bones which requires the rupture of the annular and 
interosseous ligaments. 

In Duret's case the sigmoid cavity looked outward (supination), and 
Vanheuverswyn found he could reproduce this form upon the cadaver 
by forced supination of the partly flexed forearm after division of the 
upper part of the interosseous ligament. 

Pathology. Two of the patients (von Pitha, Gripat) died of the 
associated injuries, but the displacement at the elbow was much greater 
than that observed in the other cases. 

In von Pitha' s the autopsy showed a wide separation of the radius 
and ulna from each other, complete rupture of the capsule, and of the 
annular, interosseous, and both lateral ligaments, fracture of the coro- 
noid process, and avulsion of the biceps and brachialis anticus. 

In Gripat' s case, a boy thirteen years old, the coronoid process had 
been broken off* and the olecranon had passed almost directly upward, 
remaining close to the posterior surface of the humerus ; the radius 
was displaced forward and outward. The internal lateral ligament 
had been torn away at both its insertions; the external one remained 
attached at its upper insertion, and to the broken coronoid process and 
part of the anterior ligament. The annular ligament was torn away 
at its posterior attachment to the ulna. 

Symptoms. The attitude of the limb is noted in nine cases ; in six 
it was slightly flexed, in three nearly straight ; in one case supinated, 
in the others midway between pronation and supination, or slightly 
pronated. The general appearance of the region probably resembles 
that of dislocation of both bones backward, for in three of the cases 
the anterior position of the radius was not noticed until after the ulna 
had been reduced. Excluding the two fatal cases, the displacement 
of the ulna upward is still very marked: four centimetres in Tillaux's 
case, two or three finger-breadths in Michaux's, and one and a half 
inches above the condyles in Scott's and Ferguson's ; in Tillaux's ir 
was also displaced somewhat to the inner side. In four eases the 
position of the radius is exactly noted ; in two (Bulley, Tillaux") it 



6 6 6 Di&L C4 T/OJV& 

was iu the coronoid fossa ; in Mason's it rested on the outer portion 
of the 'humerus ; in Petzholdt's it overlapped the inner edge of the 
trochlea. 

Active movements, both flexion and rotation, are impossible, and 
passive movements restricted and painful. 

In two cases (Mayer, Tillaux) reduction failed, the attempt being 
made on the fourteenth and eighth days respectively. In both the 
joint remained quite stiff. In Mason's the attempt was made on the 
nineteenth day ; prolonged efforts under ether brought the ulna into 
place, but the radius slipped toward the outer side and could not be 
entirely reduced. The final result is not known. In the others 
reduction was effected without much difficulty, usually the ulna first, 
then the radius, but in Bulley's the radius remained a little forward, 
and was finally reduced by continuous pressure upon it. 

Treatment. Traction should be made in the direction of the axis 
of the forearm to bring the ulna into place, and in case of need it 
might be well to combine it with some outward lateral flexion to avoid 
the opposition of the external lateral ligament ; after the ulna is 
reduced the radius should be pressed back into place with the thumbs 
aided by pronation and adduction of the forearm. Possibly the return 
of the radius may be impeded by the torn annular ligament. 

B. Transverse. 

Of this variety there are only two. recorded cases. Guersant's is as 
follows: The patient was a boy fifteen years old, who fell from a tree, 
three or four metres, on his left side, striking on the palm of his 
hand. The elbow w T as enormously swollen ; the transverse diameter 
was greatly increased. The head of the radius formed a considerable 
prominence entirely to the outer side of the epiphysis of the humerus 
and a little upward along its outer border. It was so far displaced 
outward that there seemed to be an interval between it and the epi- 
condyle ; the skin was very tightly stretched over it. 

The olecranon was displaced inward behind the epitrochlea, which 
it embraced in its sigmoid cavity. In the great space between the 
olecranon and radius lay almost the entire articular surface of the 
humerus. 

The forearm was semi-flexed, and in a position midway between pro- 
nation and supination ; voluntary movements were impossible, passive 
movements very restricted. There was also a fracture of the forearm 
three centimetres from the wrist. 

Wight's patient was a woman thirty years old, who had fallen while 
walking, the pronated right arm being caught under the body. Sup- 
posing the injury to be a backward dislocation he attempted to reduce 
under ether, and after failing made a closer examination. He then 
found that the radius was on the outer and the ulna on the inner side 
of the humerus. Xo other details. He reduced the radius by press- 
ing on its head while making traction and adduction, and then the 
ulna by traction and adduction (abduction ?), " using the external con- 
dyle as a fulcrum, and at the same time firmly flexing the elbow." 



CHAPTER XLVI. 

DISLOCATIONS OF THE ELBOW.— (Continued.) 

Isolated Dislocations of the Ulna and Radius. 

DISLOCATIONS OF THE ULNA ALONE. 

Sedillot, in a paper presented to the Academie des Sciences in 1887, 
was the first of modern writers to call attention to this class of dislo- 
cations, although Sir Astley Cooper had previously described as of 
this kind a specimen preserved at St. Thomas's Hospital. Malgaigne 
and other surgeons and writers strenuously opposed the interpretation 
of cases cited in support of the claim that the occurrence of this form 
is possible, and denied the possibility on anatomical grounds, claiming 
that the ulna cannot be displaced backward and upward unaccompanied 
by the radius, except after rupture of the interosseous ligament and 
those uniting the lower ends of the bones, of which there is no clinical 
evidence. The specimen figured and described by Cooper is claimed 
by them to be one of dislocation backward of both bones, and one 
presented by Robert to the Societe de Chirurgie, in 1847, was declared 
by Malgaigne to be of the same character. I have examined Cooper's 
specimen, which is still preserved at St. Thomas's Hospital, and have 
no doubt that it is simply an old unreduced backward dislocation 
of both bones, the error in interpretation having been due to a failure 
to appreciate the new formation of bone behind the external condyle. 
Malgaigne admits, however, on the authority of a case observed by 
himself, the possible dislocation of the ulna alone backward and to the 
outer side behind the radius. The dispute is in part one of terms ; it 
must be admitted, I think, that the head of the radius in some of 
the reported cases has changed its relations with the capitellum, but 
the change is a very slight one, a simple slipping backward or forward 
for a distance of a few millimetres, without a change in its level corre- 
sponding to that of the ulna. The erroneous belief in the impossibility 
of the occurrence without the extensive lacerations mentioned arose 
apparently from a failure to consider the effect of a change in the rela- 
tion of the axes of the arm and forearm, for while the occurrence of 
an isolated dislocation of the ulna backward and upward might be 
impossible, while those relations remained unchanged, yet if, the joint 
being extended, the forearm is adducted, turning upon the head of 
the radius as a centre, the olecranon must necessarily move upward 
behind the humerus ; or, the joint being flexed at a right angle, the 
same movement of adduction will displace the olecranon backward ; 
in like manner abduction of the forearm can bring the olecranon for- 
ward or downward. 

667 



(tit 



DISLOCATIONS. 



The following recorded cases 1 serve as a basis of the description to 
be given. Some in which the correctness of the diagnosis is in doubt, 
or of which I have not been able to consult the detailed reports, have 
been omitted. 



Fto. 315. 



1. Backward Dislocation. 

Backward dislocation presents itself under three forms. In the 
first, that in which the displacement is slightest, the ulna is carried 
backward, either directly or by inward rotation of the forearm about 
the radius as a centre, until the coronoid process has cleared the 
trochlea, and then is moved slightly upward behind it by adduction 
of the forearm (Fig. 315); in the second form, the movement upward 
is prolonged until the coronoid process lodges in the 
olecranon fossa ; in the third, the primary movement 
of rotation is prolonged until the olecranon lies behind 
the radius. The first form is the most common, and 
is sometimes termed " incomplete," in accordance 
with a similar use of the term in the backward dis- 
location of both bones ; of the second form there are 
only two recorded examples (Malgaigne, Wilson). 
Some writers make an additional variety, dislocation 
backward and inward, a distinction which it does 
not seem necessary to preserve. 

Cause. The cause in the larger number of cases 
has clearly been a fall upon the outstretched hand ; 
in one, Brun, a blow received upon the elbow from 
behind while the weight of the body rested upon the 
extended arm. 

In von Pitha ? s case the injury was received in such 
a way that the mode of production is clearer than in 
most accidents, and, as the case is typical in other 
respects, I reproduce the account. 

A girl six years old and her little brother were 
engaged in a trial of strength, in which each sought 
to move an open door against the other's opposition, 
the girl standing with her back against the wall and her out- 
stretched hands against the door, the hinges being at her left side. 
Two other brothers came to the help of the first, and under their com- 
bined efforts the girl's left arm suddenly doubled up with an audible 
snap, and when von Pitha examined it half an hour later, he found 
"the most distinct picture of a dislocation of the ulna backward." 
The thin arm was in almost complete extension, the forearm being 

1 Boudant, Eevue Medicale, 1830, vol. i. p. 85, quoted in full by Sedillot; Sedillot, Gazette 
Medicale, 1839, vol. vii. p. 369 ; Diday, idem, p. 393 : Brun (three cases), idem, 1844, p. 580 ; 
Robert, Gazette des Hopitaux, 1847, p. 272 ; von Pitha, Pitha and Billroth's Chirurgie, 
vol. iv. part ii. B, p. 87; Malgaigne, Luxations, p. 631; Duguet, Bulletins de la Societe 
Anatomique, 1863, p. 278 ; Mathieu, Gazette des Hopitaux, 1866, p. 330 ; Waterman, Bos- 
ton Medical and Surgical Journal, 1869, vol. lxxxi. p. 187; Wilson, Canada Journal of 
the Medical Sciences, 1880, vol. v. p. 346; Waters, Maryland Medical Journal, 1883, vol. 
x. p. 402 ; Loison, Arch, de Med. et Pharm. Mil., September, 1890, inward ; Wight, Brook- 
lyn Medical Journal, September, 1889 ; and Stimson, case here given, both forward. 




Dislocation of ulna 
alone backward, first 
form. (Sedillot.) 



DISLOCATIONS OF THE ULNA ALONE. 66$ 

slightly inclined toward the ulnar side ; the fold of the elbow was some- 
what raised by the projecting trochlea ; the olecranon was very promi- 
nent behind, but barely raised above its normal level ; the elbow was 
notably thicker, but not broader; the head of the radius was in its 
place ; pronation and supination were but slightly restricted, but the 
least movement of flexion was very painful. Reduction was easily 
accomplished by grasping with the left hand the humerus above the 
condyles, and with the right the forearm in such a way that the thumb 
and Angers specially compressed the ulna, and then supinating, abduct- 
ing, and extending until there was slight dorsal flexion ; at this moment 
he distinctly felt the lifting of the coronoid process, and on increasing 
the traction it suddenly slipped back over the trochlea with a snap. 
Pain at once ceased, and the patient could flex the joint. 

Experiments upon the cadaver by Sedillot and Streubel l indicate 
that the mode of production is similar to that of backward dislocations 
of both bones together — that is, the forearm is abducted (Streubel) or 
hyperextended (Sedillot) until the internal lateral ligament yields, and 
then rotated inward and adducted to carry the coronoid process past 
the trochlea and engage its point against the posterior surface of the 
latter. If the adduction is increased, and especially if at the same 
time the orbicular ligament is torn, the olecranon rises to a higher point 
and may pass to the inner side. If, on the other hand, adduction is 
absent and the rotation is prolonged, the olecranon is carried around 
behind the radius, and the form is produced. 

Pathology. Two specimens (Robert, Duguet) and one compound 
dislocation (Boudant) furnish but scanty information of the patholog- 
ical details, for which we must mainly depend upon experiment. Of 
the two specimens, Robert's alone was of a recent case. 

Duguet's specimen was taken from a man, fifty years old, w 7 ho had 
received the injury twenty years previously. There was anchylosis in 
the extended position, but pronation and supination were preserved. 
The ulna was displaced backward and upward so that its upper end 
was two centimetres above the line uniting the two epicondyles, and a 
nearthrosis had formed between the tip of the olecranon and the back 
of the humerus above and a little to the inner side of the olecranon 
fossa. It is probable, therefore, that the coronoid process was lodged 
in the olecranon fossa. Concerning the radius two statements are made : 
the first is that it had preserved its relations with the external condyle ; 
the second, that it was appreciably displaced forward, and preserved 
its movements of rotation. I understand these to mean that the 
head was directly below the condyle and a little in front of the 
position it would normally occupy in that attitude (extension of the 
limb). 

In Robert's case the injury was caused by a fall on the palm of the 
hand ; the limb was partly flexed, the olecranon prominent posteriorly 
and elevated ; the head of the radius could not be felt because of the 
swelling, but it could be moved backward and forward with cartilagi- 
nous crepitus. At the autopsy the coronoid process was found in the 
olecranon fossa, and the radius in place; the humerus appeared to have 
1 Streubel: Prager Viertejjahrschrift, 1850, ii. p. 54. 



670 DISLOCATIONS. 

been twisted so that its anterior aspect looked outward (in other words, 
the forearm was adducted) ; the annular ligament and some of the fibres 
of the external lateral ligament were torn. The condition of the inter- 
nal lateral ligament is not mentioned. The brachialis anticus and 
brachial artery were ruptured. 

Boudant's patient was a man forty-nine years old, who had fallen 
from the first story of a building and received a compound dislocation ; 
the wound was eighteen or twenty lines in length on the inner and 
anterior part of the elbow, and was thought to have been caused by 
contact with a large, rough stone. It seems, however, not unlikely 
that it was caused from within outward by the pressure of the trochlea 
in hyperextension of the joint. The olecranon, which was prominent 
posteriorly, could be seen through the wound, and the finger introduced 
into the latter recognized the radius in place. Reduction was easy, and 
the patient made a good recovery. 

The experiments made upon the cadaver show that the internal 
lateral ligament is always ruptured, and that the orbicular ligament 
escapes injury if the displacement is not great. 

Symptoms. In the first and second forms, dislocation backward and 
upward, the limb is usually in almost complete extension (in Duguet's 
and Waterman's cases it was flexed at a right angle), and cannot be 
flexed without causing much pain, but pronation and supination are 
free and painless. The normal deflection of the forearm toward the 
outer side is lost, and in its place may be a deflection toward the ulnar 
side. This deflection is easily recognized by the eye when the limb is 
extended, but when the joint is flexed at or near a right angle it may 
be overlooked unless comparative measurements are made ; in Diday's 
case the length of the ulnar border, from the epitrochlea to the lower 
end of the ulna, was an inch shorter than that of the other arm, while 
the radial borders were of equal length. The antero-posterior diameter 
of the joint is increased, and the fold of the elbow is filled out by the 
trochlea. 

The olecranon is prominent behind the humerus, and may rise well 
above the line of the epicondyles ; it may be nearer the epitrochlea 
than usual. The head of the radius can be felt in its place, and it is 
by the determination of this fact, together with the displacement of the 
olecranon, that the diagnosis of the variety of the dislocation is made. 

In the two recorded cases of the third form, dislocation of the ulna 
backward and outward behind the radius (Malgaigne, Wilson), the 
elbow was flexed nearly at a right angle. In Malgaigne's the forearm 
was pronated and deviated outward ; the greater sigmoid cavity was 
directed outward (sic), the coronoid process outward and forward. 
This attitude of the ulna suggests that the dislocation was not effected 
by rotation of the forearm. 

Treatment. In Duguet's case reduction was not made ; in the others 
it was easily obtained. Waterman tried Cooper's method of the knee 
in the elbow, and Skey's of traction upon the upper part of the flexed 
forearm in the line of the humerus, without success, and then easily 
reduced by hyperextension. The readiest method in the first and 
second forms appears to be that employed by von Pitha, and described 



DISLOCATIONS OF THE RADIUS ALONE. 671 

above — supination, abduction, and hypei'ex tension of the forearm. 
Malgaigne and Wilson reduced (third form) by direct pressure upon 
the olecranon, first backward to free it from the radius, and then 
inward. 

(A case described by Eichet, 1 as a new kind of dislocation by rota- 
tion, seems, from its title and from some of its features, to belong to 
this class, but the account is so incomplete that it is not available.) 

2. Dislocation Inward. 

Of this there is only one reported case, Loi son's. The patient, a 
man twenty-four years old, fell backward upon the left elbow, bruising 
the skin on the inner side an inch below the epitrochlea; the wounds 
suppurated ; the diagnosis was not made until the forty-second day. 
Then the radius was found in place, and the olecranon displaced inward 
so that the sigmoid cavity embraced the epitrochlea. Four months 
after the accident, reduction not having been made, the limb could be 
actively flexed to 80 degrees and extended to 135 degrees; rotation 
apparently well preserved. 

3. Dislocation Forward. 

March 13, 1895, I saw at the Hudson Street Hospital a man thirty- 
five years old, who had injured his right elbow in falling backward, 
the arm being caught under him. As he complained of handling I 
gave ether. The following notes were made at the time : The elbow 
is held at a right angle, but can be somewhat flexed and extended ; is 
movable laterally. The epitrochlea can be plainly felt, also the inner 
face and edge of the trochlea, the overlying flexor muscles of the hand 
having been torn away from the humerus. The tip of the olecranon 
is below and even a little in front of the trochlea, the inner anterior 
portion of the articular surface of which can also be felt on depressing 
the skin. The head of the radius is in place in front of the capitellum. 
The forearm is markedly abducted. 

Reduction was easily made by slight rotation backward (pronation) 
of the ulna and adduction of the forearm. Then by pronation and 
abduction the dislocation could be easily reproduced. When the bones 
were in place abduction of the forearm was possible, but not adduction. 
Apparently the lesions were avulsion of the flexor muscles from the 
humerus and rupture of the internal lateral ligament. The ulnar 
nerve w T as uninjured. 

The only other reported case is Wight's ; the symptoms were similar, 
and reduction was easily made. 

DISLOCATIONS OF THE RADIUS ALONE. 

Although statistics show that these dislocations are not very rare (1.4 
to 4 per cent, in the tables in Chapter X XVII.), and although the 

1 Richei : Nouveau genre do luxation incomplete du coude par pivotement. Gazette 
lies Hopitaux, 1871), p. 737. 



672 DISLOCATIONS. 

earliest writers mentioned them, yet they were almost completely lost 
sight of until about one hundred and fifty years ago, and even now 
are far from being clearly understood. Duverney, in 1751, gave a 
detailed account of two forms. Since that time observations have 
accumulated, and four varieties are now well established — the dislo- 
cations forward, backward, and outward, and one seen exclusively in 
children, and caused by traction upon the wrist, the nature of which, 
though not entirely undisputed, is generally believed to be a diastasis 
or direct separation ; it is usually termed dislocation by elongation. 

The mode of production of all the forms is still obscure, and the 
numerous experiments that have been made upon the cadaver by vari- 
ous investigators, Roser, Malgaigne, Streubel, Denuce, Pingaud, Barros, 
while they have shown how the dislocations may be produced upon the 
cadaver, have not made it clear how they actually are produced in the 
patients who come under observation ; in some cases the clinical facts 
directly contradict the conclusions drawn from experiment. 

1. Dislocation Backward. 

This was one of the forms described by Duverney, and one of the 
earliest to be accepted as proved by later surgeons. Its apparent fre- 
quency is in part due to the inclusion in the list of reported cases of 
those in which the dislocation is associated with fracture of the internal 
condyle, and probably also of others which belong in the group of dis- 
locations by elongation. Two varieties are described, the complete and 
the incomplete, the latter resting upon a few questionable and one 
well-observed case, that of Denuce : l a lad nineteen years old fell from 
a swing, his pronated arm being caught under his body in such a way 
that the blow, as shown by an ecchymosis, was received upon the 
middle of the anterior aspect of the forearm. Pain ; limitation of 
motion ; the elbow semiflexed, the forearm fixed in complete prona- 
tion. A bone-setter tried in vain to reduce it, and a fortnight later 
the patient consulted Denuce, who found " behind the elbow, on a level 
with the condyle, and to the inner side of the epicondyle, a small promi- 
nent tumor, which rolled under the finger in pronation, and was evi- 
dently the head of the radius, a little overlapping its ordinary position 
posteriorly." 

Of the complete cases the instances are much more numerous, but 
in some of them the question arises whether the upper surface of the 
radius had entirely left the articular surface of the capitellum, or was 
still in contact with it by its anterior portion ; if such contact did exist, 
the term " complete " can be properly applied only to the separation 
of the radius from the lesser sigmoid cavity of the ulna. 

The cause, in the majority of cases, appears to have been a fall upon 
the outstretched hand ; that the cause was a fall in most cases is certain, 
but whether it was upon the hand or the elbow is often far from clear, 
or whether it acted by direct impulsion or by exaggerated rotation. 

In a case reported by Cameron 2 the character and mode of action of 
the violence are more clearly shown than usual, but they are entirely 

1 Denuce : Diet, de Med. et Chir. pratiques, art. Coude, p. 777. 

2 Cameron : Lancet, 1884, vol. i. p. 885. 



DISLOCATIONS OF THE RADIUS ALONE. 673 

exceptional, and the case does not aid to clear up the obscurity in which 
the question is enveloped. The patient was a man fifty-two years old, 
who was caught between a wall and a cart backing against it in such a 
way that his forearm was compressed lengthwise between them, the 
palm of the hand being pressed against the cart, and the back of the 
elbow against the wall ; probably the hand was completely pronated. 
When seen, immediately after the accident, the head of the radius lay 
just under the skin behind the external condyle, where it formed a 
distinct projection, revealing to the eye its characteristic shape with the 
cavity on its extremity. The hand and forearm were prone ; all move- 
ments were painful, and gave the impression of considerable fixity of 
the joint. Pain at the wrist led to an examination, which showed 
that " the styloid extremity was also dislocated downward, exactly as 
in cases in which the radius is shortened by the common fracture of 
its lower extremity." 

While the character of the force and the direction of its action in 
this case are clear, pressure exerted against the lower end of the radius 
in the line of its long axis, yet it is far from being clear how such a 
force, so applied, could produce such a displacement, for the head of the 
radius is squarely placed against the anterior face of the capitellum, 
not upon an inclined surface along which it could be displaced. And 
yet, that there is something in the anatomical structure of the joint 
which permits the occurrence and forbids the rejection of the case on 
the supposition of abnormal conditions, is indicated by the fact that 
two similar cases have been reported by Wagner, 1 in which the mode 
of production was the same as in Cameron's, but the head of the radius 
was displaced to the outer side of the condyle instead of behind it, 
and a flat, wedge-shaped piece was broken off its inner side. 

Streubel, 2 in his experiments upon the cadaver, found that he could 
produce the dislocation in only one way, by hyperextending the supi- 
nated forearm until the head of the radius had been carried completely 
behind the line of the condyle, then forcing it upward, and at the same 
time bending the forearm to the radial side, and finally flexing it again 
while holding the radius pressed firmly back with the thumb of the hand 
that grasped the forearm. It is by no means probable that this rather 
complicated manoeuvre, which, moreover, has entirely failed in my 
hands, is a reproduction of what has taken place in the falls that have 
produced the dislocation. The radius is dislocated not only from the 
humerus, but also from the ulna, and this requires the rupture of the 
orbicular ligament. To effect that, something more is required than 
hyperextension of the elbow, even with the addition of direct propul- 
sion upward of the radius. Supination of the forearm will not effect 
it, and while direct propulsion backward of the bone would undoubt- 
edly produce the dislocation, the clinical facts do not indicate this as 
the cause. Possibly in hyperextension and outward lateral flexion, as 
in Streubel's experiments, the head of the radius may become engaged 
behind the slight projection of the articular surface of the capitellum 
at the bottom of the condyle, and be thereby prevented from accom- 

1 Wagner : Beilage zum Centralblatt fiir Chirurgie, 1886, No. 24, p. 93 

2 Streubel : Prager Vierteljahrschrift, 1850, vol. ii. p. 68, 



674 



DISLOCATIONS. 



panying the ulna in its return forward when the elbow is again flexed ; this 
would supply the strain necessary to separate the radius from the ulna, 
but I must add that all the attempts I have made thus to produce the dis- 
location were fruitless ; the result was always a dislocation of both bones. 
There are no post-mortem records of recent cases, and the dissection 
of those of long standing is not an entirely trustworthy indication of 
the condition and the relations of the parts when the injury is fresh. 
A case observed by Mr. Rivington l is of particular importance, because 
the position of the head is more exactly noted than is usual in the 
descriptions. The patient was a lad fourteen years old, and the injury 
had been received five months previously in a scuffle, during which he 
was violently shaken by the forearm, and thrown down, striking his 
elbow against the leg of a table. There was a marked prominence 
" at the back of the joint below the external condyle, and by the side 
of the olecranon process." " The head of the radius was displaced 
more directly backward than is usual, according to the descriptions of 
the books, not lying in any wise behind the external condyle, but a 
little overlapping the articular end of the humerus." Flexion and 
extension were almost unimpaired, pronation was good, and supination 
to more than half the usual extent. Reduction failed. 

In a specimen of an old dislocation, which had been received in child- 
hood and had existed for many years, presented by Petit 2 to the Societe 
Anatomique, the head of the radius was directly below the summit of 
the epicondyle when the elbow was flexed at a right 
angle. In another specimen found in the dissect- 
ing-room and described and figured by Sir Astley 
Cooper, " the head of the radius could be seen, as 
well as felt, behind the external condyle of the os 
humeri. The coronary ligament was torn through 
at its forepart, and the oblique had given way. 
The capsular ligament was partially torn, and the 
head of the radius would have receded still more, 
had it not been supported by the fascia which 
extends over the muscles of the forearm. The 
accompanying figure (Fig. 316) indicates that the 
head of the radius had risen very slightly above 
the lowest part of the articular portion of the con- 
dyle, and that its position was probably the same 
as in Mr. Rivington's case. 

In another specimen of old dislocation presented 
to the Societe de Chirurgie by Bernadet, 3 the head 
of the radius had been displaced a little backward, 
downward, and outward ; the external lateral liga- 
ment entirely covered the cup-shaped surface of 
the head ; the annular ligament no longer existed 
except upon the inner side, and there it was notably thickened and 
obliquely deviated. 



Fig. 316. 




Dislocation of the 
head of the radius 
backward. (Cooper.) 



1 Rivington : Lancet, 1879, vol. ii. p. 942. 

2 Petit: Bull, de la Societe Anatomique, 1874, p. 904. 

3 Bernadet: Bull, de la Soc. de Chir., 1861, p. 462. 



DISLOCATIONS OF THE RADIUS ALONE. 675 

In the specimens which Streubel obtained by experiment he always 
found the anterior portion of the capsule torn and the capitellum 
projecting through the rent ; the external lateral ligament was more or 
less torn at its anterior border, the internal lateral ligament uninjured ; 
the annular ligament was always torn in front, either at its insertion 
by the lower sigmoid cavity, or further outward ; the oblique ligament 
was torn, doubtless in consequence of the exaggerated supination. 

These 'facts, though not numerous or entirely free from objection, 
indicate that the position of the dislocated head of the radius, even in 
full extension, is lower than that commonly assigned to it in systematic 
descriptions and shown in the plates accompanying them — that it does 
not rise above the shallow groove which marks the posterior and lower 
margin of the articular surface of the capitellum. At this point the 
upper margin of the head would be but very little below the axis of the 
joint, and consequently would have to move over only a short distance 
in full flexion and extension of the limb. 

In recent cases the elbow is slightly flexed, the forearm pronated ; 
voluntary and communicated movements are painful and limited in 
range, but in old cases the freedom of motion is almost completely 
restored, supination remaining the most imperfect. The diagnosis is 
made by recognition of the head of the radius behind its normal place 
in extension, behind and below it in flexion at a right angle. It may 
lie close beside the olecranon or further to the outer side. Its projec- 
tion, unless the swelling is considerable, is such that the entire extent 
of its concave upper surface can be felt. Measurement of the radial 
border of the forearm from the epicondyle to the styloid process of the 
radius may show some shortening, half an inch according to Streubel. 

Treatment. The dislocation in recent cases has usually been reduced 
promptly by pressure on the head of the radius, aided or not by trac- 
tion upon the wrist, and this method has succeeded even when several 
weeks had passed since the receipt of the injury. But in some cases 
reduction has been impossible or the displacement has shown a marked 
tendency to recur, both circumstances probably due in the recent cases 
to the interposition of a portion of the capsule, but in the older ones 
also to permanent change in the relations of the shafts of the radius 
and ulna and to adhesions between them. This interposition of the 
capsule has been demonstrated in one or two cases in which arthrotoniv 
has been done (see Chapter XLVIL). Probably the best position to 
give the limb during the attempt is that of supination and full exten- 
sion, and if direct pressure does not then restore the bone to its place 
traction should be made at the wrist, and the forearm gradually bent 
to the inner side, and then the direct pressure renewed. 

In some old cases excision of the head has improved function. 

2. Dislocation of the Radius Outward. 1 

Excluding the cases in which the dislocation is accompanied by frac- 
ture of the ulna in its upper portion and those in which the displace- 

1 For bibliography sec: Nelaton, Path. Chir., vol. ii. p. 400; Gerdy, Arch. gen. do Mr,!.. 
1835, vol. vii. p. 1(51; Parker, Now York Journal of Medicine, 1852, p. L89; Pitha ami 



676 



DISLOCATIONS. 



Fig. 317. 



ment outward is comparatively slight and is associated with a more 
important displacement backward or forward, the recorded instances 
of this injury are very few, and in some of these, even, the description 
justifies a doubt whether they should not rather be placed in one of 
the two other classes. 

In Nelaton's case the dislocation occurred in childhood and had 
existed for twenty years ; the position of the radius is shown in Fig. 
317. Flexion and extension were preserved; supination was impos- 
sible. 

Wagner reported to the German Surgical Congress, in 1886, three 
cases of dislocation outward complicated by fracture of the inner por- 
tion of the head of the radius. In the 
first two cases the injury was caused 
by pressure against the back of the 
flexed elbow while the palm of the 
hand was resting against a firm object 
in front. Thus, a lad, eighteen years 
old, pushing a coal-wagon on a tram- 
way with his forearm pronated and 
flexed, was struck on the elbow by 
another wagon coming up from behind. 
A year had elapsed since the accident 
when the first case was seen, during 
which the joint had been steadily grow- 
ing stiffer. The elbow was flexed at a 
right angle ; flexion, extension, and 
rotation were almost entirely lost. On 
the outer side of the external condyle 
w T as a large bony prominence, the 
thickened and immovable head of the 
radius ; there were no abnormalities in 
the other parts of the joint, and no 
sign of a fracture of the ulna. The 
head of the radius was excised ; it was 
found thickly enveloped in fibrous tis- 
sue, to which the appearance of thick- 
ening was due, and had lost from its 
inner side a flat, wedge-shaped piece 
constituting about one-sixth of its di- 
ameter. The fragment w T as found ad- 
herent to the capsule and was also removed. Recovery took place 
without accident, and the mobility of the joint steadily increased for 
some time. At the time of the report, nine years later, flexion could 
be made to an angle of 80 degrees, extension to 150 degrees, pronation 
was almost normal, supination somewhat restricted. 

In the second case, a man, twenty-six years old, was injured in the 

Billroth, Chirurgie, vol. iv. Part II. B. p. 92; Pineraud, Diet. Encyclop. des Sc. Med., art. 
Coude ; Wagner, Beilage zura Centbl. fur Chir., 1886, No. 24, p. 93; Lobker, ibid., p. 92; 
Bartels, Arch, fur klin. Chir., 1874, vol. xvi. p. 643; Schroter, ibid., vol. xlvi. p. 4. 
Thoraassin's and Chedieu's cases, quoted by Malgaigne, seem to belong among the 
anterior dislocations. 




Dislocation of the head of the radius 
outward ; the trochlea is much broadened. 
(Nelaton.) 



DISLOCATIONS OF THE RADIUS ALONE. 677 

same manner, and was seen while the injury was fresh. Reduction 
\\as effected, after several unsuccessful attempts, by, first, adduction of 
the flexed limb, then by the utmost possible abduction, with supina- 
tion, of the completely extended limb, combined with pressure upon 
the head of the radius. When the dressings were removed, a month 
later, passive movements were very painful and limited, and, as no 
improvement followed, excision was done five months after the accident. 
The head of the radius was found thickened and absolutely fixed, and 
the fragment reunited to it by a loose fibrous union; the failure of 
union was attributed to the interposition of a small piece of the artic- 
ular cartilage. Recovery followed without accident, but the mobility 
of the joint was not increased. 

In the third case the patient had received his injury twenty-two 
years before, when six years old, by a fall from a horse. " The head 
of the radius stood outside upon the external condyle," and was flat- 
tened on its inner side ; there was no sign of any injury to the ulna. 
The movements of the joints were completely normal. 

Lobker, in a paper read before the same congress, reported two cases 
of the same combination of dislocation outward with fracture of the 
inner portion of the head of the radius treated by excision. In each 
case the fragment had become united to the adjoining parts by a pedicle. 

Of the 26 cases collected by Schrotter 3 were complicated with frac- 
ture of the head of the radius and 13 with that of the ulna. 

Bartels reported a unique case in which the heads of both radii had 
gradually become displaced outward. The patient was a man forty- 
three years old, who, while lying in hospital with a broken leg, called 
the surgeon's attention to his elbows. He said that the deformity 
dated from his eleventh year ; his father had at that time put him at 
hard work, usually pushing a loaded cart ; pain was soon felt in the 
elbows, and increased steadily, but he was kept at work. The head of 
the radius rested on the outer side of the external condyle when the 
limb was fully extended and supinated ; when extended and pronated, 
the head was less prominent, and rested partly on the outer part of the 
articular surface of the capitellum, and when flexed and pronated the 
head returned to its place. 

Barros could produce the dislocation experimentally in only one way, 
by pressure against the ball of the hand, and simultaneous forcible 
adduction of the forearm, by which the external lateral ligament was 
torn. 

The general symptoms in the recent cases showed no special or char- 
acteristic features ; the limb appears to have been partly flexed and 
pronated, and the movements of the joint restricted. In the older 
cases, the normal movements were more or less completely re-estab- 
lished. 

The diagnosis is made by recognition of the presence of the head oi' 
the radius on the outer side of the condyle. Reduction, except when 
there is fracture of the head or interposition of the torn orbicular liga- 
ment, should be easy by adduction of the forearm and direct pressure 
on the head of the radius. 



678 DISLOCATIONS. 



3. Dislocations Forward. 



These are the most common of the three varieties, even excluding 
from them the not unusual subluxation which occurs in children, and 
will be described in the next section, and those cases which are com- 
plicated by fracture of the ulna (vide infra). The dislocation is char- 
acterized by the position of the head of the radius in front of its 
normal position when the forearm is extended, and above it when the 
forearm is flexed at a right angle. Several authors describe two forms, 
the complete and the incomplete, including in the latter those cases in 
which in flexion at a right angle the head of the radius has not entirely 
left the articular surface of the capitellum, but remains in contact with 
its upper portion. The distinction between complete and incomplete is 
an arbitrary one and does not seem to deserve to be retained, for even 
in the former the head of the radius sometimes descends upon the 
articular surface of the capitellum when the limb is extended. 

The causes mentioned in the reported cases include falls upon the 
hand or upon the elbow, and traction upon the forearm. In experi- 
ments upon the cadaver the dislocation has been produced by forced 
pronation, in which, according to Filugelli, quoted by Streubel, a ful- 
crum is established by contact between the radius and ulna in their 
upper third at the point at which they cross, the effect of which is to 
cause the head of the radius to move forward and inward, with rupture 
of the anterior portion of the annular ligament when the pronation is 
exaggerated. 

As in the two preceding varieties, the mode of production is far from 
clear. That the head should be displaced by direct violence is not 
difficult to comprehend, but the cases in which this mode of production 
can be invoked are few. Traction upon the forearm, combined prob- 
ably with exaggerated pronation, must also, I think, be admitted as an 
occasional cause, especially in children, both because of its efficiency 
to produce the dislocation upon the cadaver, and because the histories 
of one or two cases in adults are not open to any other explanation, 
as in Boyer's case of the footman who slipped while getting up behind 
a carriage, and remained suspended by his hands. It seems probable 
that some of the cases in which the injury was received in childhood, 
and remained unreduced, may have been dislocations by elongation, and 
that the head remained fixed in its new position, or perhaps was still 
further displaced by use. In a fall upon the hand, it seems probable 
that the dislocation could be produced only by hyperextension and 
pressure upon the lower end of the radius, aided by supination or pro- 
nation, and this opinion is confirmed by experiment. A case of Mal- 
gaigne's 1 seems to support this theory, for at the patient's death, seven 
weeks after the accident, the posterior fourth of the head of the radius 
was found to have been broken off. In two of Lobker's 2 cases a 
piece was broken from the outer portion of the head, which suggests, 
what is probable also on other grounds, that abduction of the forearm 
may also be a factor. 

1 Malgaigne : Loc. cit., p. 651. 

2 Lobker : Beilage zum Centralblatt fur Chir., 1886, No. 24, p. 92. 






PLATE LIV 




Fig. 1. — Backward Dislocation of Elbow, 




Fig. 2. — Dislocation of Upper End of Radi 



DISLOCATIONS OF THE RADIUS ALONE. 679 

In a. case reported by Ross 1 the dislocation occurred during an epi- 
leptic convulsion and was attributed to muscular action, the unopposed 
contraction of the biceps and pronator radii teres. 

Pathology. No autopsies have been reported in recent cases. In 
experiments upon the cadaver (Streubel, Pihgaud) the capsule has been 
found torn transversely in front close to its attachment to the humerus 
(Fig. 318), and the annular ligament untorn and encircling only the 
neck of the radius while the head projected forward through the rent 
in the capsule and rested, by its posterior edge only, against the artic- 
ular surface of the capitellum. 

Fig. 318. 




Hilton's case of dislocation of the head of the radius forward. 

In a number of cases, ten or twelve, the opportunity has arisen to 
examine old dislocations. Maigaigne has described his own, quoted 
above, in which the posterior fourth of the head of the radius was 
broken off and the capsule was intact, and two specimens in the Musee 
Dupuytren (cases of Desault and Prestat). Cooper 2 describes and 
figures a specimen preserved at St. Thomas's Hospital ; the others are 
those of Danyau, 3 Debruyn, 4 two cases, Hilton, 5 Trelat, 6 Kronlein, 7 a 
specimen in the Museum at Zurich, and Lobker, the two cases above 
referred to ; see, also, Sch rotter. 8 

In Malgaigne's, Danyau's, one of Debruyn's, Trelat' s, and the two 
specimens of the Musee Dupuytren the annular ligament was stretched 
but not torn ; in Hilton's its upper portion was torn, but the more 
external and superficial fibres remained intact and were closely wrapped 
about the neck of the radius ; in Cooper's the annular, oblique, fore- 
part of the capsular, and a portion of the interosseous ligament were 
torn through. With reference to some of these cases the question has 
been raised whether the annular ligament found at the autopsy was 
not one of new formation. 

The head of the radius rests, in partial flexion, upon the anterior 
surface of the external condyle above and usually somewhat to the 
inner side of its normal position, and either in contact with the coro- 
noid process or (Hilton) separated from it by the interposed tendon of 
the brachialis anticus. In some cases a piece has been broken from 
its posterior or outer border. In several of the cases a hollow had 

1 Streubel : Loc. cit., p. 75. 2 Cooper : Loc. cit., p. 3912. 

8 Danyau: Annales de laChir. Francaise et Etrangere, 1841. vol. ii. p. 72. 

4 Debruyn : Annales de la Chir. Francaise et Etrangere. 1843, vol. ix. p. 88. 

5 Hilton : Guy's Hospital Reports, 1847, vol. v. p. 93. 

6 Trelat: Bull, de la Societe Anatomique, 1S58, p. 487. 
"• Kronlein : Deutsche Chirurgie, Lief. :2(>, p. 44. 

8 Schrotter: Arch, far klin. Chir., vol. xlvi. 



680 DISLOCATIONS. 

formed for its reception on the anterior surface of the humerus ; the 
new articulation was either entirely above the old one, or included the 
upper part of the capitellum, or (Trelat) extended over the outer por- 
tion of the front of the trochlea. The head of the radius was deformed 
and had suffered the loss of more or less of its cartilage of incrustation ; 
in some cases it was enlarged, in others diminished in size. In Kron- 
lein's specimen an extensive outgrowth of bone had formed upon the 
inner side, giving the upper end of the bone an appearance similar to 
that of the upper end of the femur, and articulating with a new cavity 
upon the humerus ; it is stated that the movements of rotation had been 
completely restored. 

An interesting feature in Hilton's case was that the radius had been 
displaced bodily upward along the ulna, and this displacement had pro- 
duced changes at the wrist. 

Malgaigne observed and called especial attention to abduction of the 
forearm, which does not appear to have been observed by others. It 
furnishes a satisfactory explanation of the displacement of the radius 
upward as well as forward, which could not otherwise be accounted for 
except by such a change in the level of the bones at the wrist as was 
noted in Hilton's case. Abduction of the forearm might easily be 
overlooked while the joint is partly flexed unless comparative measure- 
ments are made. 

Symptoms. The elbow is slightly flexed and the forearm almost 
always more or less pronated ; in a few cases supination has been pres- 
ent. Voluntary and communicated movements are painful, and of the 
latter flexion nearly to a right angle and almost complete extension are 
possible, pronation is usually complete, but supination much restricted. 
Abduction of the forearm has been noted, possibly it is quite common, 
and when present it can be demonstrated by comparative measurements 
of the radial borders of the two forearms, the injured one being short- 
ened. The region of the elbow is swollen in front and on the outer 
side ; the absence of the head of the radius from its normal position is 
shown by the depressibility of the soft parts on the outer side of the 
joint below the condyle, and its presence in the fold of the elbow can 
generally be recognized by the finger ; sometimes it is so prominent 
there that it appears to be subcutaneous, and the saucer-like depression 
of its upper surface can be traced when the joint is extended. Flexion 
of the forearm is abruptly arrested at or near a right angle by the 
impact of the head of the radius upon the front of the humerus. 

In the older cases the restoration of function may be almost com- 
plete, the range of motion being limited only in extreme flexion and 
supination. 

In Hilton's case the associated changes at the wrist caused a corre- 
sponding deformity there, abduction of the hand ; and it seems not 
unlikely that even in some recent cases the wrist may be painful or 
distorted. 

Treatment. Reduction has been easy in some recent cases, and diffi- 
cult or impossible in others. The measures which have been most 
successful are traction upon the radius at the wrist, the forearm being 
supinated and extended, combined with pressure upon the head of the 



DISLOCATIONS OF THE RADIUS ALONE. 681 

radius. Malgaigne suggests, very properly, that adduction of the fore- 
arm would be more likely than traction to overcome the overriding of 
the radius. Hilton reduced the displacement in his specimen, which 
had existed for many years, by placing a small wedge between the 
upper surface of the radius and the humerus, and then flexing the fore- 
arm by pressing upon the lower end of the ulna ; when flexion was 
nearly complete direct pressure upon the head of the radius forced it 
backward into place. The effect of this device was to displace the 
radius downward along the ulna to a distance equal to the thickness of 
the wedge, and to rupture the ligaments which bound the two bones 
together. A marked tendency to recurrence has been frequently 
noticed, and has generally been attributed to interposition of a portion 
of the capsule. I am inclined to think it due, in some cases at least, 
to the persistence of this bodily displacement of the radius upward. 
If so, the condition would be shown, after reduction, by loss of the 
outward inclination of the forearm in full extension, and the effort 
should be made to overcome it by restoring this angle by forcible 
abduction. 

The position of the rent in the anterior portion of the capsule sug- 
gests that after reduction the joint should be kept flexed, and although 
recurrence of the dislocation has taken place with the limb in this 
position, it does not seem so likely to favor such recurrence as the 
extended position. 

4. Dislocation by Elongation, or the Subluxation of Young 

Children. 1 

Under these names is described an injury which is very frequently 
observed, but the nature of which, after nearly two centuries of dis- 
cussion, is still in dispute. Its features are well marked ; a young 
child, generally less than three years old, is lifted or pulled by the 
hand ; it cries out with pain, and refuses to use the limb, which hangs 
motionless by the side, somewhat flexed at the elbow, and more or less 
pronated. A careful examination fails to discover marked changes in 
the anatomical relations of the bones at the elbow or wrist ; passive 
motion at both joints is free, but painful, except supination, which is 
resisted ; often during the manipulations made in the examination, or 
on forced supination, a slight click is heard, and the child at once is 
able to use the limb freely without pain. 

As early as 1671 Fournier described the injury as an incomplete 
dislocation characterized by relaxation of the ligaments and elongation 
of the radius, meaning by the latter direct separation downward or 
diastasis. Nearly a hundred years later, Duverney gave a clear and 

1 The papers upon this subject are numerous ; the following bibliography contains the 
more important : Gardner, London Medical Gazette, 1837, vol. xx. p. 878 ; Hodges, Boston 
Medical and Surgical Journal. 1862, vol. lxvii. p. 129 ; Goyrand, Gazette niedieale de 
Paris, 1837, p. 115, and Bull, de la Societe de Chirurgie, 1861, p. 605; Pingaud, Diet. 
Encyclopedique, art. Coude, p. 580; Hamilton, New York Medical Journal, Jan. 3. 1885, 
p. 8 ; Duverney, Maladies des Os, 1751 ; Bouley, De radii superioris extremitatis dimotione, 
in infantibus frequentiori, 1787; Rendu, Gazette niedieale, 1841, p. 301 ; Perrin. Journal 
de Chirurjjie de Malgaigne, vol. v. p. 145; Streubel, Prager Vierteljahrschrit't. 1850. vol. 
ii. p. 90; Van Arsdale, Annals of Surgery, June, 1889 ; A. Broea. La pronation douloureuse 
des jeunes enfants, Gaz. des Hop., 1903, No. 5(5. 



682 DISLOCATIONS. 

exact description of it as an injury occurring frequently in children ; 
he attributed it to forcible traction at the wrist, and gave as its chief 
symptom the opposition to supination of the forearm, and as the treat- 
ment forcible supination with pressure from before backward upon the 
head of the radius followed by flexion of the elbow. He thought the 
injury was not merely an elongation of the radius, but also the escape 
of its head below the edge of the orbicular ligament. Nearly a cen- 
tury and a half has passed since the publication of his views, and but 
little has been added to his description of the etiology, symptoms,- or 
treatment, and while the years have brought many other theories con- 
cerning the pathology his is the one that is now most widely held. 

In 1787 Bottentuit presided at the presentation, and, according to 
Malgaigne, was probably the real author, of a thesis by Bouley before 
the Ecoles de Chirurgie, in which the theory of the agency of forced 
pronation in the production of the injury was advanced; it was argued 
that in this movement the radius and ulna came into contact at the 
point where they crossed each other near the elbow, and that, the 
movement being continued, the head of the radius was displaced for- 
ward or outward. 

At the beginning of the present century Martin, in France, 1809, 
and Monteggia, in Italy, 1814, described the injury and reported cases, 
but the former, unfortunately, appears to have encountered also some 
dislocations backward, and he not only included them in the same 
group, but he also thought that the radius was dislocated backward in 
all, and this opinion has survived in a measure until the present time, 
and has led systematic writers to describe a dislocation backward as 
one of the forms, although it does not appear that there is any other 
authority for the statement than Martin. 

As the injury is one that seems but rarely to fall under the observa- 
tion of the general surgeon, probably because of the facility with 
which it is reduced, the authors of .the surgical text-books either made 
no mention of it or followed in their brief descriptions the account 
given by Martin, or by those who had copied from him. But between 

1836 and 1850 several cases were published in England and in France, 
and new theories concerning its nature were advanced. Gardner in 

1837 and Rendu in 1841 attributed the fixation to the locking of the 
bicipital tuberosity behind the ulna, but the latter, who in two cases 
had made the important observation that the wrist also was swollen 
and tender, added to this supposed locking of the tuberosity, which he 
regarded as probably exceptional, a rupture of the ligaments of the 
wrist. Perrin, in 1849, thought the head of the radius was caught 
below the lower edge of the lesser sigmoid cavity, and Goyrand, who 
saw a large number of cases, thought the lesion was an incomplete 
dislocation, in which the displacement was so slight as to cause no 
recognizable deformity at the elbow. Malgaigne, 1854, included it 
among the incomplete dislocations forward, and others did likewise. 

In 1850 Streubel made the theory of incomplete luxation more 
definite, by showing that if the forearm of the cadaver of a young 
child was forcibly pronated, the head of the radius moved forward, 
and the posterior portion of the capsule w T as forced in by atmospheric 



DISLOCATIONS OF THE RADIUS ALONE. 683 

pressure between the radius and the capitellum, and that if then the 
pronation was diminished, the slight displacement of the radius and 
the interposition of the capsule would persist even while gentle move- 
ments of the joint were made ; hut that under sudden extension and 
supination the normal relations would be established. Jn like manner, 
forced supination would displace the radius backward, and lead to 
interposition of the anterior portion of the capsule. In the bodies of 
adults neither manipulation would produce this result. 

In 1856 Chassaignac 1 described, under the title "paralysie doulou- 
rmse desjeunes enj'ants" a number of cases of the injury under dis- 
cussion, together with others of a different nature, and attributed the 
symptoms in all to injury of the nerves of the limb. Finally, in 
1861, Goyrand 2 returned to the subject in a lengthy paper, in which 
he abandoned his previous view 7 and advanced the last new theory, 
that the lesion was situated not at the elbow, but exclusively at the 
wrist, and consisted in a dislocation of the triangular fibro-cartilage in 
front of the lower end of the ulna. His experiments showed that in 
complete pronation the fibro-cartilage was carried so far forward as 
almost entirely to uncover the end of the ulna, and that in forced pro- 
nation the uncovering became complete. In reply to a question asked 
by Velpeau, he admitted that the displacement did not persist upon 
the cadaver unless the hand was held- upw T ard and supinated, but he 
thought that the tonic contraction of the muscles in the living would 
maintain it. He did not explain why such a lesion should be more 
easily produced in a child than in an adult. 

It may be worth while to add that the editor of the Medico- Chirur- 
gical Review, in 1839, thought the injury was a separation of the 
upper epiphysis of the radius, and Fougeu, in 1861, a separation of 
the lower one. 

Pingaud, 3 in his experiments upon the cadaver, found, as Goyrand 
had similarly done in 1837, that the head of the radius could be 
drawn out through the orbicular ligament by forcible adduction of the 
forearm, so far that its anterior edge would engage below the lower 
border of the ligament (Fig. 319), and the bones would remain sepa- 
rated by a distance of about a quarter of an inch, but without dis- 
placement of the radius forward, backward, or outward, unless forced 
pronation was added to the adduction, in which case the head moved 
forward ; and as this condition of the parts coincided with a limitation 
of the freedom of rotation of the forearm similar to that observed 
clinically in the cases in question, and as the normal relations of the 
parts were restored by the same manoeuvres which relieved the little 
patients, he reached the conclusion that the nature of the lesion 
observed clinically was the same as that which he had produced 
experimentally, and that the clinical injury was, therefore, a disloca- 
tion of the radius downward below the annular ligament, or, in other 
words, that Puverney's theory was the correct one. He showed fur- 
ther, that the younger the child the more easily could this displace- 

1 Chassaignac : Archives generalesde Mod., 18r>(>, vol. i. p. 053. 

2 (Joy rand : Bull, de la Societe de Chir., 1861, p. 596. 

3 Pingaud : Lot-, eit., 1878. 



684 



DISLOCATIONS. 



ment be effected, and the more complete, circularly, would it be. He 
would not assert that this was the only cause of the clinical condition, 
but contented himself with proving that it was at least one ; his reserve 
being apparently due to the inapplicability of the explanation to the 
reported cases in which the radius was said to have been displaced 
backward, cases which we have seen to rest only upon Martin's asser- 
tion. His experiments have been repeated, and his results verified by 
others ; Poinsot accepts his explanation fully for the usual cases, and 
Streubel's for those of displacement backward. 



Fig. 319. 




Subluxation of the head of the radius. (Pingatjd.) 

Turning now to the clinical evidence, for there have been no post- 
mortem examinations, it appears that the injury is common in young 
children between the ages of one and three years, and is rarely seen 
after the age of six years, and not infrequently recurs. Goyrand (loc. 
cit., 1861) had seen at least two hundred cases in thirty years, and 
quotes Chabrely {Journal de Medecine de Bordeaux, October, 1860, 
p. 481) as saying that hardly a month passed, he might say hardly a 
week, in which he was not called to a case, and Fougeu as having seen 
thirty-five cases ; in the discussion that followed the reading of Goy- 
rand's paper, Marjolin stated that he had seen about sixty cases. 
Snedden J saw ten cases in ten years in private practice ; and Linde- 
man 2 saw twenty-four cases and Van Arsdale one hundred in two years 
in dispensary practice. The cause is traction upon the arm at the hand 
or wrist, as in lifting a child, or in holding it when it stumbles, and in 
two cases in drawing the arm through the sleeve of the dress. It 
seems to me that exaggerated pronation does not enter into the mechan- 
ism by which the lesion is produced, but that the violence is simply 
traction exerted upon the extended elbow, possibly combined with 
adduction, for traction would tend to make the limb exactly straight, 
and thus overcome the normal inclination of the forearm outward ; or 
the grasp upon the forearm may be so firm that an actual inward incli- 
nation would be produced in case the effort was not a simple traction, 
but was combined with a movement that tended to swing the child 

1 Snedden : British Medical Journal, 1882, vol. i. p. 499. 
2 Lindeman : British Medical Journal, 1885, vol. ii. p. 1058. 



DISLOCATIONS OF THE RADIUS ALONE. 685 

upward along a curve whose centre was its wrist and whose radius 
was its extended arm. At least, in lifting a living child by the 
arm I have not been able to make exaggerated pronation, for rota- 
tion at the shoulder is so free that the limit of pronation is not easily 
reached, and this is unquestionably true when the child is lifted by 
both hands. 

The child at once cries out in pain and refuses to use the limb, which 
hangs motionless by its side, or is supported, with the elbow slightly 
flexed, across the front of the abdomen ; the wrist is completely or 
partly pronated. Examination shows sensitiveness at the outer por- 
tion of the elbow, in some cases also at the back of the wrist, and in 
others exclusively at the wrist, with swelling after the lapse of from 
thirty to thirty-six hours. The head of the radius is sometimes 
slightly but distinctly displaced forward, but in most cases no other 
change than a slight longitudinal separation between the radius and 
the capitellum is recognizable. There is pain on pressure over the 
head of the radius. 

Although the child does not voluntarily move the joint, it can be 
freely moved by the surgeon in every direction except supination, and 
will sometimes be held by the child in such a position as may be given 
to it. In only one recorded case, Duges, 1 was the limb in supination ; 
with that exception the constant and pathognomonic symptom is the 
interference with supination. 

These facts, taken in connection with the results of experiment, indi- 
cate that Duverney's opinion was correct and that the injury consists 
in the escape of the front portion of the head of the radius below the 
orbicular ligament, and that it is produced by traction and adduction 
of the extended forearm. Goy rand's last explanation — dislocation of 
the triangular fibro-cartilage at the wrist — cannot maintain itself against 
the overwhelming clinical evidence of the existence of a lesion at the 
elbow, supported, as it is, by experiment, especially since it has no 
better foundation than the impression that the click which was heard 
during reduction was. produced at the wrist and not at the elbow. 
Against its correctness are the facts that although exaggerated prona- 
tion will effect such a dislocation, yet there is nothing to prove that 
the displacement will not immediately correct itself when the limb is 
released, and that there is not only no proof of the intervention of 
exaggerated pronation in clinical cases, but it was, furthermore, cer- 
tainly absent in some, and probably in all. The only difficulty is to 
explain the well-established symptoms of injury at the back of the 
wrist in some of the cases. Possibly such cases may be of a different 
character from the others, actual dislocation backward of the lower 
end of the ulna (vide infra), and Goyrand's explanation may be true 
of them ; or the symptoms may be due to an associated sprain of the 
wrist. 

The experience of Chassaignac, who treated his cases as paralytic 

and saw them gradually recover, indicates that the lesion may be spon-. 

taneously corrected ; but, on the other hand, there is reason to think 

that some of the eases of forward dislocation of the head oi' the radius 

1 Dug&s: Journal hebdomadaire, 1831, vol. iv. p. 196. 



(686 DISLOCATIONS. 

found in adults, which had existed from childhood, were originally of 
this kind, and that the head had gradually become displaced further 
forward. All who have treated cases agree that reduction is easily 
effected, usually by supination ; some add flexion of the elbow. 

DISLOCATION OF THE HEAD OF THE RADIUS WITH FRACTURE 

OF THE ULNA. 

The coincidence of a fracture of the shaft of the ulna with disloca- 
tion of the head of the radius is not infrequent, and, since the discovery 
of either of the two injuries may lead the surgeon to overlook the 
other, the possibility of the coexistence should always be borne in mind. 
Malgaigne attached so much importance to this warning that he formu- 
lated and italicized the following two recommendations : 

1 . In any fracture of the ulna alone look for a dislocation of the 
radius. 

2. In every fracture of the forearm in which the swelling extends 
above the elbow, remember that simple fracture is rarely accompanied 
by so much swelling, and carefully explore the articulation. 

To complete the warning a third precaution should be added, namely, 
that in every dislocation of the head of the radius alone, fracture of 
the ulna should be sought for. 

The complication has received the attention of most systematic 
writers upon dislocations, and has been made the subject of mono- 
graphs by Malgaigne, 1 Greiner, 2 and Dorfler. 3 The latter collected 
nineteen cases, but the injury appears to be of more frequent occur- 
rence than this fact would indicate, for Malgaigne saw four cases, von 
Pitha two or three, and Dorfler reports four cases from the practice of 
the surgeon under whom he was serving. I have seen at least ten. 

The cause in a certain number of cases — five of Dorfler's nineteen — 
has been direct violence, as the kick of a horse, received upon the inner 
or inner and posterior aspect of the upper part of the ulna, first break- 
ing that bone and then driving the head of the radius forward and 
outward from its place ; in others it has been a fall upon the arm, and 
it is uncertain whether the ulna was broken by direct or indirect vio- 
lence. In Gerdy's case the patient declared that he fell upon his 
extended hand ; and in one that came under my care in August, 1885, 
the patient, a boy seven years old, had fallen from a w T agon and sus- 
tained a compound fracture of the ulna at its middle, the wound in the 
skin being in the centre of the anterior aspect of the limb and having 
been produced from within outward by the sharp end of one of the 
fragments ; the radius was displaced forward, upward, and inward so 
far that its concave upper surface could be distinctly felt. There was 
no bruise on the back of the forearm, and I thought the fracture had 
been produced by indirect violence, a fall on the hand. 

1 Malgaigne : Revue inedico-chirurgicale, vol. xiii. pp. 82 and 90. 

2 Grenier : Recherckes sur la luxation du radius que complique la fracture du tiers 
supei-ieur du cubitus. These de Paris, 1878. 

3 Dorfler : Fractur der ulna in ih rem oberen Drittel combinirt mit Luxation des Radius ; 
Deutsche Zeitschrift fur Chir. ; 1886, vol. xxiii. p. 338. 



DISLOCATIONS OF RADIUS WITH FRACTURE OF ULNA. 687 

The only autopsical record I have found is one by Marchand, 1 and, 
unfortunately, it is not entirely clear. It is stated that the external 
lateral ligament was torn, the ulna was broken in its upper third, and 
the head of the radius was displaced to the outer side of the epicon- 
dyle ; the annular ligament was untorn, but u no longer surrounded 
the neck of the radius ; it seemed rather to embrace the radial capsule 
(cupule, head ?), and the radius seemed to have escaped below it." 

Dorfler's experiments showed that the parallelism of the radius and 
the lower fragment of the ulna was preserved, with production of an 
angle in the ulna at the point of the fracture ; the annular and anterior 
ligaments were torn. The limb was shortened, and crepitus was per- 
ceived on handling it. Clinically, a prominent feature is the marked 
swelling at the elbow, due in part to the displacement of the radius 
and in part to inflammatory reaction. The displacement of the radius 
is usually forward, sometimes forward and inward, forward and out- 
ward, or directly outward. 

Among the complications were observed subluxation of the lower 
end of the ulna, wound of the integument either by the direct action 
of the causative violence or from within outward by the end of the 
fragment, making the fracture compound, fracture of the epicondyle 
or external condyle, and more or less paralysis of the extensor muscles 
of the wrist and fingers due to stretching or rupture of the musculo- 
spiral or posterior interosseous nerve. 2 

The prognosis is good if the displacements are promptly corrected ; 
and even if the dislocation of the radius persists the restoration of 
function may be nearly complete. 

On the other hand, failure of union of the fracture has been noted 
(Norris 3 ), and persistent extensor paralysis (Dorfler). 

Reduction in recent cases has been easy ; the most suitable method 
appears to be traction upon the extended limb, followed by direct press- 
ure upon the radius and then by flexion of the elbow. The extended 
position during traction is desirable in order to avoid the interposition 
of the torn anterior ligament. After reduction the limb should be 
kept flexed within a right angle, and midway between supination and 
pronation. 

1 Marchand: Bull, de la Societe Anatomique, 1874, p. 680. 

"Stetten (Annals of Surg., Aug., 1908, p. 275) reports a case successfully treated by- 
Prof. Kammerer and collects eight reported cases. 
- Norris : American Journal of Medical Sciences, vol. xxxi. p. 20. 



CHAPTEE XLVII. 

DISLOCATIONS OF THE ELBOW.— (Continued.) 

Treatment of Old Dislocations — Congenital and Pathological Dislocations,. 

TREATMENT OF OLD DISLOCATIONS. 

The loss of mobility in old dislocations of the elbow, especially of 
the backward ones, is often so great that the disability is serious ; the 
patient is unable to bring the hand to the head or chest, and is able to 
use it only in the arc of a circle whose radius is nearly equal to the 
length of the extended limb, and he may, in addition, possess only such 
rotation as can be effected by movements at the shoulder. Although 
successful attempts to reduce dislocations of several months' standing 
were occasionally reported, yet failure was the rule, and the only means 
of alleviating the conditions were fracture of the olecranon and excision 
of the joint, operations which, while they increased the range of mo- 
tion, brought with them disadvantages of their own, such as loss of 
active extension and lack of solidity, which disinclined the surgeon to 
offer, and the patient to accept them. 

Consideration of the anatomo-pathological conditions of an old unre- 
duced backward dislocation not only fully explains the difficulty of 
effecting reduction, but even makes it appear surprising that reduction 
should ever have been satisfactorily accomplished. The overriding of 
the bones along the back of the humerus leads to the formation of 
new cicatricial bonds between the olecranon and the humerus and to 
the establishment of new attachments by the torn lateral ligaments so 
far above and behind the centre of motion of the old joint that almost 
no flexion is possible without their rupture or elongation, and the 
return of the bones to their place can be effected only after a more 
extensive rupture of these soft parts than that which accompanied the 
dislocation. In attempting to rupture these bonds by forced flexion 
the forearm is used as a lever the fulcrum of which is situated on the 
ulna below the coronoid process, and the rupturing strain is exerted 
through the olecranon upon the ligaments and adhesions connected 
with it, and it is not to be wondered at that this process should so 
frequently have been broken in the manipulation. In addition, the 
greater sigmoid cavity promptly fills with cicatricial tissue, partly of new 
formation and partly furnished by the upper part of the posterior por- 
tion of the capsule which slips in between it and the back of the 
humerus and permanently occupies the concavity which should, after 
reduction, embrace the trochlea ; this pad of tissue is found so firmly 
united to the cartilage of the olecranon that its removal in the reported 
arthrotomies has required the use of the knife. The adhesion of the 



OLD DISLOCATIONS OF THE ELBOW. 



689 



capsule to the articular surface of the front of the trochlea and the 
capitellum has not been found to be so close, and the cartilage of their 
surfaces has been found, even after the lapse of several months, almost 
entirely unaltered in appearance. 

Furthermore, the injury is common in the young, in whom the osteo- 
genic power of the periosteum is great and in whom the epiphyses are 
still growing. The effect of the injury, especially if the periosteum is 
stripped up, is, therefore, to produce new formations of bone around 
the joint which contract adhesions with the other bones or mechanically 
interfere by interposition to prevent the reduction of the dislocation ; 
and, further, the epiphysis of the humerus, relieved of the pressure 
normally exerted upon it by the radius and ulna, grows more rapidly 
and irregularly, and its articular surface may thus lose its shape and 
become unfit to receive the others again. This deformity by exagger- 
ated growth has been especially noticed in the capitellum (see Patholog- 
ical and Congenital Didocatio7is), the extension being downward and 
forward. 

Fig. 320. 




Old dislocation of elbow. 



New socket for head of radius, 
and trochlea. 



Bony union between ulna 



These changes are clearly incompatible with successful reduction by 
the means employed in fresh cases, even if the force employed be suffi- 
cient to rupture the adhesions and bring the bones down to the proper 
level. It is true that successes have been occasionally reported, but the 
reports rarely go beyond the statement that reduction was accomplished, 
and they leave the subsequent history of the case and degree of re- 
establishment of the functions unrecorded. Until quite recently the 
only methods employed have been forcible attempts to reduce by trac- 
tion and the breaking of adhesions, sometimes aided by subcutaneous 
division of the tendon of the triceps, or of adhesions on the sides and 
back of the joint, increase of the range of motion by the same means 
without reduction, reduction after fracture of the olecranon by forcible 
flexion, and excision of the joint. 

Albert says that Listen, more than forty years ago, successfully 

reduced an old dislocation after subcutaneous division of all tense 

bands, and that in 1847 Blumhart successfully practised arthrotoray 

in a similar case, making two lateral incisions, and dividing through 

44 



690 DISLOCATIONS. 

them all the adhesions that opposed reduction. This case appears to 
have been entirely lost sight of, and it was not until thirty years later, 
in 1879, that Trendelenburg, 1 in a paper recommending temporary 
division of the olecranon to facilitate operations upon the elbow-joint, 
reported a case of incomplete outward, or outward and backward, dis- 
location of both bones with avulsion of the epitrochlea which he had 
treated by making an incision along the tendon of the biceps, and chis- 
elling away enough bone from the lower end of the humerus in front 
of the coronoid process to allow flexion to a right angle ; the result was 
good to that extent. A little later Volker 2 reported a case of incom- 
plete outward dislocation of the left elbow of,- six months' standing in 
a boy thirteen years old, in which, after division of the olecranon, he 
had divided the adhesions, dissected away the new tissues in the sig- 
moid fossa, and had then been able to reduce ; as the change in the 
shape of the bones favored recurrence he removed the head of the 
radius. His incision was U-shaped, the sides extending along the 
borders of the triceps, and the bottom of the U crossing the olecranon 
at the point where it was to be divided. The position of the limb 
(anchylosis in almost complete extension) and the evidences of serious 
pressure upon the ulnar nerve were important factors in the determi- 
nation to operate. He was so pleased with the result that he looked 
forward with confidence to the adoption of the method in all old dis- 
locations with much disability. 

Trendelenburg 3 promptly claimed priority in the suggestions of pre- 
liminary division of the olecranon, and reported a case of backward 
dislocation of both bones of eight weeks' standing successfully treated 
in the same manner. His incision was a curved transverse one, the 
convexity directed upward, crossing the median line well above the 
olecranon, and the flap was then dissected and reflected downward to 
the point at which the olecranon was to be divided ; this division of 
the olecranon was done with a chisel. Because of difficulty in bringing 
the olecranon down the limb was dressed in extension, but after the 
nineteenth day, when the wound was healed, the position was gradu- 
ally changed, and four weeks later the joint could be flexed to a right 
angle. The olecranon reunited solidly in this case and in Volker's. 

In 1885 Nicoladoni 4 published a short paper on the application of 
arthrotomy to old dislocations of various joints, and included in it the 
report of two cases in which he had practised it at the elbow. The 
first case was an almost complete outward dislocation of the left elbow 
in a lad sixteen years old, which had existed for eight months ; the 
epitrochlea was broken off and drawn under the trochlea ; the limb 
was in extension, flexion was entirely lost, but rotation was preserved. 
An incision eight centimetres long was made in front along the inner 
border of the trochlea, and through this the fractured epitrochlea was 
removed ; a second incision of the same length was made on the outer 
side of the joint through which, after removal of a small piece of bone 

1 Trendelenburg : Archiv fur ldin. Chir., 1879, vol. xxiv. p. 790. 

2 Volker: Deutsche Zeitschrift fur Chir., 1880. vol. xii. p. 541. 

3 Trendelenburg : Centralblatt fiir Chir., 1880, p. 833. 

4 Nicoladoni : Wiener med. Wochenschrift, 1885, p. 728, 



OLD DISLOCATIONS OF THE ELBOW. 



691 



that had been broken from the condyles, the soft parts were separated 
from the radius and the humerus ; then, through a longitudinal cut 
made in the tendon of the triceps, the adhesions between the olecranon 
and the back of the humerus were separated, and the bones were then 
easily restored to place. The wound healed after slight suppuration, 
passive motion was begun after the third week, and the patient was 
dismissed after seven and a half weeks with the elbow flexed and 
movable through an arc of 35 or 40 degrees. Nine months later he 
wrote that he could flex and extend the joint freely, but that rotation 
was not quite so free. 

The second patient was a large, powerful man, forty-one years old, 
with a backward dislocation that had existed for six months. The 
limb was almost completely extended and immovable; there was some 
passive rotation. The olecranon was situated unusually high. Two 
lateral incisions, each sixteen centimetres long, were made ; through 
the first, over the outer condyle in front of the head of the radius, the 



Fig. 321. 



Fig. 822. 




New formation of bone on an old 
unreduced dislocation. 




Result of operative reduction of old dislocation. 



soft parts were separated from the bone, leaving the periosteum undis- 
turbed, into the trochlea and above the fossa trochlears in front and 
behind ; through the second incision, on the inner side of the elbow, 
the flexor muscles were cut away close in front of the epitrochlea, and 
the separation of the soft parts from the bones completed. The greater 
sigmoid cavity was found filled with hard cicatricial tissue, which was 
cut and scraped away after separation of the posterior attachment of 
the orbicular ligament. Reduction was then easily made. Recovery 



692 DISLOCATIONS. 

took place without incident, and the patient was dismissed at the end 
of four weeks, the wounds being almost healed. There was good active 
rotation, but very little flexion ; passively, there was complete extension 
and flexion to a right angle. 

In 1886 I operated upon a five-months' backward dislocation in a 
girl eleven years old by an incision on the outer side and division of 
the olecranon. My attention had been attracted by a mass of bone 
attached to the back of the humerus and capping the head of the 
radius, which I believed to be of new formation and to require removal. 
The conditions found on exposure (Fig. 321) confirmed this opinion ; 
the mass was cut away and the dislocation was reduced. The case is 
given in detail in the New York Medical Journal, April 2, 1887. The 
result was not satisfactory, recurrence having taken place under the 
dressing. The information thus gained fixed my attention upon the 
importance of the mass of new bone, the formation of which I attrib- 
uted to the stripping up of the periosteum from the back of the con- 
dyle by the displaced head of the radius, enabled me properly to 
estimate the difficulties,. and encouraged me to operate in other cases. 
In 1891 l I reported seven additional cases, in five of which I had 
operated with good results. I have since operated upon several other 
cases ; the results have all been flexion within a right angle and exten- 
sion varying from 120 to 170 degrees, and preservation of rotation. 

The operation 2 is done by a long incision on the outer side exposing 
the head of the radius and the mass of new bone ; the latter is freely 
chiselled away, and the capitellum exposed by free division of the soft 
parts, keeping the knife at a little distance from the bone so as not to 
damage the periosteum. Through the incision the sigmoid fossa is 
cleared of fibrous tissue. A second incision, about four inches long, 
is then made on the inner side, curving close behind the epitrochlea or 
its site, the ulnar nerve is drawn forward and the olecranon. freed; if 
the epitrochlea has been broken off and displaced upward and back- 
ward it must be detached from the humerus, preserving its relations 
with the lateral ligament. The cleaning of the sigmoid cavity is then 
completed. If the attachments of the olecranon to the back of the 
humerus have been thoroughly divided reduction can now be easily 
made and maintained, unless the dislocation has existed so long that 
the flexor muscles of the hand have become permanently shortened, in 
which case they must be partly divided close to the humerus. 

Vamossy 3 reported Mcoladoni's experience — nine cases successfully 
treated by arthrotomy between 1886 and 1890. Kunn 4 reports MaydFs 
experience of five cases treated by resection and one by arthrotomy ; 
Helferich 5 reports two cases successfully reduced by the aid of two 
lateral incisions, and Luksch 6 reviews the subject on the basis of 60 
collected cases. 

1 Stimson : On the Treatment of Old Dislocations of the Elbow, New York Medical 
Journal, October 24, 1891. 

a Stimson : Operative Surgery, third edition, 1895, p. 139. 

3 Vamossy : Wiener klin. Wochenschrift, December 11, 1890. 

4 Kunn: Internat. klin. Rundschau, September 6, 189]. 

6 Helferich : Deutsche med. Wochenschrift, August 10, 1893. 
6 Luksch : Deutsche Zeit. fur Chir., 1900, vol. lvii. p. 413. 



DISLOCATIONS OF THE ELBOW. 693 

In old incomplete outward lateral dislocations little is to be hoped for 
from forcible subcutaneous rupture of the adhesions, for the common 
interposition of the fractured epitrochlea cannot thus be overcome, and 
the probabilities are decidedly against the success of an attempt to 
remove by this means the cicatricial obstacles on the inner side. The 
choice lies between improving the attitude by forcible flexion, if the 
limb is extended, and arthrotomy, the internal incision being made in 
front of the trochlea rather than upon its side. 

In old dislocations of the radius alone, in which partial or complete 
anchylosis renders an operation desirable, the examples quoted in the 
preceding chapter may serve as guides. In those cases in which the 
dislocation has occurred in childhood and has been followed by exag- 
gerated growth in length of the radius excision of its head is the only 
suitable operation, and in other cases it is probably the means most 
likely to improve function. 

Sprengel 1 reports a case of dislocation backward and outward of the 
head of the radius of five weeks' standing in a boy six years old in 
which he effected reduction and obtained a perfect functional result by 
arthrotomy and removal of a portion of the back of the capsule that 
was interposed between the head of the radius and the ulna. He made 
an anterior incision along the edge of the supinator longus, exposed 
the musculo-spiral nerve and its two branches and drew them outward 
with the outer flap ; by this means the capsule was freely exposed to 
view, and he was enabled to see that the rent was on its outer side, and 
then by drawing the head of the radius outward with a sharp hook the 
obstacle to reduction was found to be a fold of the posterior portion of 
the capsule (probably part of the annular ligament) interposed between 
the radius and ulna, and firmly adherent to the lesser sigmoid cavity. 
After having liberated this fold he was able to replace the head of the 
radius and to close with catgut sutures the rent in the capsule except 
over a small space on the outer side. 

He refers to a case of backward dislocation of the head of the radius 
in which he obtained a similar success by arthrotomy and separation of 
the capsule from the upper surface of the radius. 

CONGENITAL AND PATHOLOGICAL DISLOCATIONS. 

Although a considerable number of cases have been reported as con- 
genital dislocations of the upper end of the radius, yet in many of them 
the proof that the deformity existed at birth is defective ; in some 
it was noticed at so early a period that the probability of its con- 
genital existence is great ; in others, and even in some in which both 
radii were affected, the displacement can be referred with equal plausi- 
bility to causes operating after birth, and the alterations in the shape 
of the bones to the effect of the displacement and the changed func- 
tional conditions. 

To the 13 alleged cases briefly quoted and analyzed by Malgaigne, 
9 of which are quoted in detail by Gurlt, 2 may be added several that 

1 Sprengel: Centralblatt fax Chirurgie, 1886, p. 153. 

2 Gurlt: Beitrage zur Vergleieh. path. Anat. dor Gelenkkrankheiten. 1853. p. 317. 



694 DISLOCATIONS. 

have been since reported, those of Humphry, 1 Hayem, 2 Mltscherlich, 3 
Allen, 4 Hamilton, 5 Phillips, 6 Pye-Smith, 7 Heele, 8 and Herskovits. 9 
In addition is a case, a dislocation forward, observed and briefly men- 
tioned by Krb'nlein. 10 

The first 4 were examined post mortem, the others only clinically. 
In 5 of them the dislocation was backward, in 3 forward ; in all both 
radii were dislocated. Humphry's, Hayem's, Allen's, and Hersko- 
vit's were in adults, of whom no previous history was obtained. In 
Humphry's the lower part of the left ulna was lacking, evidently 
because of defective development ; the right ulna was firmly anchy- 
losed to the humerus nearly at a right angle, and was eight inches long, 
its lower end was well formed and was on the usual level with the 
radius ; the radius was also eight inches long, and its head was dis- 
placed upward and rested against " the forepart of the ridge that 
ascends from the outer condyle to the shaft," it was somewhat irregu- 
lar in shape, and its extra length was developed in its shaft and not in 
its neck as in several of the other reported cases. The trochlea of the 
humerus was imperfect. The displacement upward was clearly the 
result of the elongation of the radius, whatever the cause of the orig- 
inal displacement from contact with the capitellum may have been. 

Mitscherlich's patient was a girl six years old who had been born 
with clubfoot ; both elbows were deformed, and this defect was thought 
also to have existed from birth. The head of the radius could be felt 
in front of the outer half of the coronoid process ; extension was per- 
fect, but flexion was limited on the right side to an angle of 70 degrees 
and on the left to one of 110 degrees; both hands were supinated. 
Excision of the left elbow was done by von Langenbeck with the 
object of increasing its range of motion, and the child died in conse- 
quence of the operation. The specimen showed that the trochlear 
surface of the humerus was narrowed in front by extension upon it of 
the exceptionally large circular surface for the head of the radius. The 
articular surface of the ulna was normal, but the radius was not in 
contact with it. 

Allen's specimen was taken from the body of an elderly man with- 
out history. Both elbows were affected ; flexion was normal, extension 
possible only to a right angle ; rotation was entirely lost, the limbs 
being fixed in pronation. Both radii were displaced backward, but 
only the left elbow is described in detail. The specimen was not pre- 
sented as an example of congenital dislocation, but only to show the 
changes effected in the bones in consequence of unreduced dislocation 
in early life. These changes modified the shape of the lower end of 
the humerus and of the radius. The radius crossed the front of the 
ulna and was united with it by bony union for a distance of about three 

1 Humphry : Medico-Chirurgical Transactions, vol. xlv. p. 296. 

2 Hayem : Bull, de la Societe Anatomique, 1864, p. 56. 

3 Mitscherlich : Arch, fur klin. Chir., 1865, vol. vi. p. 218. 

4 Allen : Glasgow Medical Journal, 1880, vol. xiv. p. 44. 5 Hamilton : Loc. cit., p. 888. 

6 Phillips: British Medical Journal, 1883, vol. i. p. 773. 

7 Pye-Smith : Lancet, 1883, vol. ii. p. 993. 

8 Heele : Lancet, 1886, vol. ii. p. 249. 

9 Herskovits : Wiener med. Presse, February 12, 1888. 
10 Kronlein : Deutsche Chirurgie, Lief. 26, p. 97. 



DISLOCATIONS OF THE ELBOW. 695 

inches at their upper part; below this part the shaft of the radius was 
much thickened. The neck of the radius was one and a half inches 
long, so that the head was carried well upward behind the humerus on 
the inner side of the olecranon, and this overriding was further increased 
by the abnormal growth of the external condyle downward and out- 
ward, the extent downward of the growth being estimated at half an 
inch. The trochlear surface was deformed, mainly by the loss of much 
of its inner lip. The olecranon fossa was so far filled up that the sep- 
tum between it and the coronoid fossa was one-third of an inch thick. 
The shaft of the ulna was small ; its lower end was normal and pre- 
served the usual relations with the radius. The specimen appears 
closely to resemble those of the earlier cases reported by Sandifort, 
Dubois, and Verneuil, and has as much, or as little, reason to be 
thought congenital as most of the others. It is of value in the inter- 
pretation of the changes observed in other specimens. 

Herskovits's patient was a man twenty-one years old ; the head of 
each radius was displaced backward and outward, the capitellum small. 
Flexion was nearly complete, extension to 135 degrees, pronation com- 
plete, supination lost. No history of injury. 

For details of other cases, see first edition. 

The arguments upon which the attribution of a congenital character 
was based in most of the older cases and in those of Humphry and 
Hayem, and which apply equally well to Allen's, are the existence of 
the deformity on both sides and the changes in the shape of the artic- 
ular ends of the bones ; in Humphry's and in Deville's there is in 
addition the lack of the lower part of the ulna. 

The irregularities in the bones may, in part at least, be fairly attrib- 
uted to the change in their relations, especially the very notable one of 
elongation of the neck of the radius reported in several cases. This 
is in keeping with similar instances of overgrowth at other points 
where the normal conditions of pressure have been lost, and with the 
coincident elongation downward of the external condyle of the humerus 
noted in Allen's case and in one of R. W. Smith quoted by Gurlt. 1 
It requires only that the displacement should occur before the growth 
of the skeleton is complete. 

Blodgett 2 has recently reported a case and collected 50 others. The 
displacement in one-eighth was outward, in the others about equally 
divided between backward and forward. Supination was lost or 
much restricted in nearly all ; flexion restricted when the displacement 
was forward, extension when it was backward. Elongation of the 
upper end of the radius existed in three-fourths, bony fusion with the 
ulna in one-third. In nearly half of the cases some other deformity 
was present, most often partial deficiency of the radius or ulna. In 3 
cases the head of the radius was excised, with gain of flexion and 
extension in 2 and of rotation also in 1 of them. 

Permanent retraction of the pronators, due to prolonged mainte- 
nance of the attitude, must be a serious obstacle to the establishment 
of supination. 

1 Gurlt: Loo. cit, p. 320. 

2 Blodgett: Am. Journ. Orthop. Surg., 190(5, vol. 3, p. 253. 



696 DISLOCATIONS. 

The only recorded case of dislocation of both bones of the forearm 
at birth is one reported by Chanssier and quoted by Pingaud. 2 A 
young woman during the ninth month of pregnancy felt her child 
move so vigorously that she almost lost consciousness. The move- 
ments were repeated three times in the course often minutes ; delivery 
took place normally at term. The child was weak and presented a 
complete dislocation of the forearm backward. Malgaigne thought it 
probable that the lesion was produced, not by the convulsive action of 
the muscles, but by the striking of the limb against the Avail of the 
uterus. 

A few instances of dislocation due to pathological changes within 
the joint, such as fungous arthritis or relaxation of the ligaments in 
the course of an acute illness, have been reported. 

1 Pingaud : Diet. Encyclopedique des So. Med., art. Coude, p. 606. 



CHAPTER XLVIII. 

DISLOCATIONS AT THE WRIST. 

Dislocations of the Lower Radio-ulnar Joint — of the Radio-carpal Joint — of 
the Carpal Bones — Carpo-metacarpal Dislocations. 

DISLOCATIONS OF THE LOWER RADIOULNAR JOINT. 

These dislocations, obscurely mentioned by the earlier writers, were 
first described, according to Malgaigne, in 1771, by Desault, who 
reported five cases and said he had observed a great number of others. 
He spoke of the injury as a dislocation of the radius, but Boyer and 
Dupuytren preferred to call it a dislocation of the ulna, and their choice 
has been generally accepted and followed. Both traumatic and patho- 
logical forms have been described. The reported cases are com- 
paratively few if those cases are excluded in which the injury is a 
complication of a fracture of the lower end of the radius, and those 
injuries observed in young children which are generally thought to be 
a subluxation of the head of the radius, but which some considered dis- 
locations of the lower end of the ulna ; few surgeons who have reported 
their experience have seen more than a single case. Tillmanns 1 col- 
lected 48 cases in addition to one observed by himself, of which the 
dislocation of the ulna was forward in 16, backward in 18, and inward 
in 9, and in 5 the direction was not stated ; but in 3 of the first group, 
8 of the second, all of the third, and 1 of the fourth, there was also 
fracture of the radius, and in 4 others the ulna perforated the skin and 
there is reason to think the radius also was fractured. Excluding the 
cases complicated by fracture and including only 3 of Desault's 5, 
there remain 12 dislocations forward and 10 backward ; to these may 
be added 2 backward and 3 forward seen or collected by Hamilton, 3 
forward collected by Poinsot, 1 forward of my own, 2 3 forward by 
Hoist, 3 Le uven, 4 and Thon, 5 and 3 backward by Ridlon, 6 Horrocks, 7 
and Berger, 8 making a total of these two varieties of 22 forward and 
15 backward. The reported dislocations inward or, more strictly speak- 
ing, downward and inward, are really dislocations of the broken end 
of the radius and the attached carpus upward ; to these may be added 
also the few cases of dislocation of the head of the radius (q. v.) in 
which the entire bone has been displaced upward along the ulna. 

Dislocations Backward (of the Ulna). 

The cause in most of the cases tabulated above was exaggerated 
pronation of the wrist ; in some the mechanism is not indicated, and 

1 Tillmanns: Arch, der Heilkunde, 1874, vol. xv. p. 249. 

2 Sfcimson : New York Medical Journal, May 25, 1889. 

3 Hoist : Centralbl. fiir Chir., June 20, 1891. * 4 Leuven : Ztlblatt fur Chir.. 1906, p. 1128. 
5 Thon : Deutsche Zeitschrift fur Chir., vol. 84, parts 1 and 3. 

,; Ridlon : New York Medical Journal, April 25, 1891. 

7 Horrocks: Lancet, June 27, 1891. 8 Berger: LTnion Med.. April 13, 1895. 

697 



698 DISLOCATIONS. 

in others it is not clear. Possibly some of the cases of its alleged pro- 
duction in infants by traction upon or pronation of the hand belong 
among dislocations of the radius by elongation (q. v.). Sometimes the 
exaggerated pronation has been effected by external violence, as in 
Boyer's case, in which a lad engaged his hand between the spokes of a 
moving wheel ; sometimes by muscular action, as in one of Desault's, 
a washerwoman who was wringing clothes, or in one of Rognetta's, a 
carpenter who w r as drilling a hole in a plank ; Dalechamp's patient 
was bitten at the wrist by a horse. 

The pathology has not been shown by direct examination of either 
recent or old cases, and the only experiments bearing upon it are those 
of Goyrand, quoted in Chapter XLVL, and they show only that by 
exaggerated pronation the triangular fibro-cartilage uniting the radius 
and ulna could be carried so far forward as to clear the end of the ulna 
entirely ; he did not succeed in producing by this means a dislocation 
that would maintain itself without the aid of pressure upon the hand. 
It seems probable that in the clinical cases there was also rupture of 
the posterior radio-ulnar ligament. 

Symptoms. The hand is slightly or markedly pronated ; its adduc- 
tion has been noted by some, and diminution of the transverse diameter 
of the wrist by others. Flexion and extension of the wrist are free ; 
supination difficult. 

The deformity consists in a marked projection of the low r er end of 
the ulna on the back of the wrist, and a corresponding depression in 
front ; the ulna may, in addition, slightly overlap the end of the radius, 
so that its axis if prolonged downward would pass to the middle finger. 

In connection with these may be mentioned a unique case reported 
by Schmid l of dislocation of the radius forward from the ulna and 
carpus, caused by a fall upon the hand. 

The diagnosis appears to be easy. Malgaigne calls attention to the 
danger of mistaking the cause for the effect in old cases in which the 
dislocation follows a chronic arthritis, and also of overlooking an asso- 
ciated fracture of the radius. 

Reduction. Reduction has always been readily effected by direct 
pressure on the radius, aided sometimes by abduction or supination of 
the hand ; occasionally supination alone has been sufficient. Even in 
old cases — sixty days — reduction has been easily made. 

Recurrence has been noted in three cases. In one of Hamilton's the 
dislocation had existed twenty years, but the movements of the limb 
were perfect. 

Dislocations Forward (of the Ulna). 

Dislocation of the lower end of the ulna forward appears commonly 
to have been caused by direct violence acting in opposite directions upon 
the lower ends of the radius and ulna while the hand was more or less 
supinated. It does not clearly appear that the cause has ever acted by 
carrying the movement of supination beyond its normal limit, although 
it is not improbable that this was the case in one or two instances. 
1 Schmid : Correspondeiiz-Blatt d. Wiirttemberg arztl. Landvereins, November 16, 1892. 



DISLOCATIONS AT THE WRIST. 699 

No post-mortem examination lias been reported, and the pathology 
of the injury can, therefore, only be inferred. Desault, however, met 
with a specimen of an old dislocation in the cadaver of a man sixty 
years old; the hand could not he extended, and rotation was very 
limited. The sigmoid cavity of the radius was filled with cellular 
tissue ; the head of the ulna, situated in front of this cavity, rested on 
a sesamoid bone to which it was attached by a capsular ligament. 
Other injuries had contributed to the loss of motion. 

In an entirely unique case reported by Valleteau l the dislocation 
was compound. The patient's forearm had been caught between the 
spokes of a moving wheel ; the ulna projected twenty-eight lines 
through the skin, crossing the front of the radius, which appears not 
to have been broken. 

Symptoms. The forearm is partly pronated or in varying degrees 
of supination, the wrist flexed or extended, rotation difficult and pain- 
ful. The lower end of the ulna is prominent in front, with a corre- 
sponding depression behind, and sometimes displaced toward the outer 
side so that it overlaps the front of the radius and its axis is directed 
toward the middle of the hand. The radius maintains its relations 
with the carpus. In my case I could not determine the position of 
the triangular fibro-cartilage. 

The diagnosis is easy, but search should be made, as in the preced- 
ing variety, for the possible coexistence of a fracture of the radius. 

The best method of reduction appears to be by direct pressure upon 
the ulna and counter-pressure on the radius. 

Dislocations Inward and Downward (of the Ulna). 

Dislocations inward and downward have been observed in connec- 
tion with fracture of the radius or, very rarely, with dislocation of its 
upper end, and are to be deemed complications or incidents of the 
other and more important injury. 

In like manner, the serious complication of perforation of the skin 
by the ulna has occurred only once except in connection with fracture 
of the radius. 

Pathological dislocations have been reported as the consequence of 
chronic suppurative arthritis and also of non-suppurative arthritis 
provoked by a sprain or by a fracture of the radius. Possibly the 
case reported by Rognetta, 2 of a negro who suffered from an habitual 
dislocation of the ulna backward gradually produced by the effects of 
his occupation as a woodsawyer, belongs in this category, the ligaments 
having become relaxed in consequence of an arthritis set up by the 
constantly repeated mechanical violence of the movement. 

DISLOCATIONS OF THE RADIO-CARPAL JOINT. 

These dislocations, long thought to be common because fracture of 
the lower end of the radius was habitually supposed to be a disloca- 

1 Valleteau : Gazette Medieale, 1836, p. 250. 

2 Rognetta: Archives gen. de Med., 1834, vol. v. p. 396 



700 DISLOCATIONS. 

tion until Dupuytren forced a recognition of the error, are now known 
to be of infrequent occurrence. Dupuytren, in the vigor of his cor- 
rection of the error, went to the other extreme and pronounced them 
unknown or of very great rarity, and this assertion has colored the 
general opinion concerning their frequency even to the present time. 
The statistics that have since been collected are not entirely trust- 
worthy, perhaps, for the error in diagnosis appears still to be made 
and not all reported cases can be unhesitatingly accepted, but there is 
reason to think that the rarity is not very great, and there are enough 
well-authenticated cases to make it possible to trace a general descrip- 
tion of the injury. Malgaigne collected 14 cases, 8 of backward, 6 of 
forward dislocation. Parker 1 collected 33 cases, 23 backward and 10 
forward. Tillmanns, 2 1874, collected 24, 13 backward and 10 for- 
ward; and Servier 3 in 1880 collected 26 besides 1 observed by him- 
self, 13 backward, 13 forward, and 1 outward, of which 19 were not 
contained in Tillmann's paper. I saw 1 and collected 13 cases pub- 
lished between 1880 and 1887, 12 backward and 2 forward, and it is 
worthy of note that 5 of these were reported in the British Medical 
Journal within six weeks of one another, March and April, 1880, the 
reports of the last 4 having been called out by that of the first. 
Albert speaks of 5 within his knowledge or observation. Even sup- 
posing Parker's 33 to include all of Malgaigne's and Tillmanns's, and 
counting 19 of Servier's, this would still give a total of about 70 cases 
more or less well authenticated, the correctness of the diagnosis in a 
number of them being entirely beyond question. 

The necessity of receiving with some caution those cases that have 
been observed clinically and reported with scanty detail is shown by 
the errors in diagnosis that have been made by experienced surgeons 
fully aware of the difficulty. Malgaigne 4 narrates three striking cases. 
At the time when Dupuytren was first questioning the correctness of 
the diagnosis in which fracture of the lower end of the radius was 
habitually taken to be a backward dislocation of the wrist, a patient 
presenting all the usual signs of this injury died at the Hotel Dieu. 
Pelletan declared it to be a dislocation, Dupuytren a fracture, and the 
former did not vary from his opinion until after the last stroke of the 
scalpel had exposed the bone and showed the injury to be a fracture 
with crushing of the lower end of the radius. In 1834 Roux made 
the diagnosis of dislocation backward in the case of a child that had 
fallen from a tree ; again dissection proved it to be a fracture, with 
separation of the epiphysis. Still more remarkable was a case reported 
by Chassaignac 5 in which he excised the projecting ends of the radius 
and ulna, thinking the case was dislocation ; on careful examination it 
proved to be a separation of the epiphysis of the radius. The diffi- 
culty is probably not so great in dislocations of the carpus forward. 

The dislocation may be complete or incomplete backward or for- 
ward, and in one case was incomplete outward ; it may be simple or 
compound, or associated with fracture of the radius or ulna. Appar- 

1 Parker: Transactions of the South Carolina Medical Association. Abstract in the 
New York Medical Record, 1876, vol. vi. p. 396. 

2 Tillmanns : Loc. cit. 3 Servier : Gazette Hebdom., 1880, p. 211. 

4 Malgaigne : Loc. cit., p. 703. 

5 Chassaignac : Bull, de la Societe de Chir., 1868, p. 225. 



DISLOCATIONS AT THE WHIST 701 

ently fracture of the edge of the articular surface of the radius on the 
side toward which the carpus is dislocated is not infrequent; such 
fracture of the posterior lip of the radius is known in this country as 
"Barton's fracture," but it appears to me properly to belong among 
the dislocations, the fracture being only an incident or complication. 
The incomplete dislocations are mainly those in which only the outer 
portion of the carpus, the scaphoid and semilunaris, is dislocated from 
the radius, while the inner portion maintains its relations with the 
triangular fibro-cartilage and ulna ; this variety appears to be produced 
by a movement of rotation (pronation or supination) in which either 
the radius or the carpus is kept stationary while the other moves away 
from it ; it appears to be sometimes associated with disturbance of the 
relations of the lower radio-ulnar joint. 

In addition to the traumatic, a few pathological and congenital dis- 
locations have been reported. 

Dislocations Backward. 

Causes. The causes of this dislocation are characterized by great 
violence, as a fall from a height upon the palm of the hand ; in some 
cases the wrist appears to have been flexed forward, " doubled under " 
the patient, in a fall while walking, or from a slight elevation. 

In two almost identical cases, Billroth l and Rydygier, 2 the mode of 
production is clearly shown ; in the former, the patient, while pressing 
with the palm of his hand against a railway car in an effort to 
arrest its motion, was struck upon the back of the elbow by another 
car moving in the opposite direction, and a compound dislocation of 
the wrist was produced, the articular surfaces of the radius and ulna 
projecting through the skin on the palmar surface. Rydygier' s patient 
was caught in the same way between a wagon and a wall alongside of 
which it was moving. 

Pathology. The pathology is illustrated by a number of post-mortem 
examinations, and by some cases complicated by wounds which per- 
mitted direct examination of the joint. The autopsy that has been 
reported with most detail is that of a case observed by Voillemier. 3 
The patient was a man twenty-seven years old, who had fallen from the 
third story of a building, and received injuries which caused his death 
in four hours. The violence that caused the dislocation of the wrist 
was apparently received upon the palm of the hand while in dorsal 
flexion. The external and posterior ligaments were ruptured, the 
anterior was torn away from the radius, and the internal was intact 
but was separated from the ulna by avulsion of its styloid process. 
The tendons and muscles of the back of the forearm were not torn, 
but had been stripped off the radius, bringing with them the perios- 
teum and small pieces of attached bone. The superficial flexor muscle 
was widely perforated and torn by the styloid process of the radius at 
its inner portion, that corresponding to the tendons of the ring and 
little fingers, the remainder being pushed to the outer side together 
with the median nerve and radial vessels. 

1 Billroth: Arch, fur klin. Chir., vol. \. p. 601, quoted by Tilluiauus. 

' 2 Rydygier: Deutsche Zeitschrift fur Chir.. L881, vol. xv. p. 289. 
3 Voillemier: Arch. geu. de Med., IS,"?}), vol. vi. p. 401. 



702 DISLOCATIONS. 

In Lenoir's case a narrow fragment of the posterior articular border 
of the radius had been broken off; it remained attached to the capsule 
and was displaced backward with the carpus. This is the so-called 
" Barton's fracture of the radius" (p. 302). In no other autopsy 
of a backward dislocation has this fracture been reported, but it has 
been suspected to exist in some of the cases observed clinically, and a 
few specimens of the reunited fracture without history are in existence. 

In a case quoted in the Centralblatt fur Chirurgie, 1884, p. 279, both 
styloid processes were broken. 

In one of my own the semilunar bone remained attached to the 
radius, and the scaphoid was broken. This attachment of the semi- 
lunar was noted by Couteaud, 1 together with a fragment of the cunei- 
form. His paper contains 15 cases of compound backward dislocation. 

Of the incomplete form, that in which only the outer portion of the 
carpus is dislocated, the only case given in sufficient detail is that of 
Dupuy: 2 the patient, a young and muscular porter, while trying to 
lift a cask had his hand forcibly supinated while the radius remained 
pronated. On examination two hours later the hand was found flexed 
and half supinated, while the radius was pronated. Both styloid pro- 
cesses could be distinctly felt, that of the ulna in its normal relations 
with the carpus, but that of the radius and the articular surface of the 
latter projecting as a ridge on the posterior aspect of the wrist. No 
crepitus ; no shortening of the limb. Reduction was effected by trac- 
tion and direct pressure. 

In short, the dislocation is habitually accompanied by an extensive 
laceration of the ligaments, especially the anterior and external ; avul- 
sion of the posterior lip of the articular surface of the radius may take 
the place of rupture of the posterior ligament. The extensor tendons 
are lifted from their grooves but not torn ; the flexors may be torn or 
pushed to the outer side by the projecting radius ; the median nerve 
and radial artery have always escaped injury, even when the radius 
has been driven through the skin. The carpus may be displaced 
directly backward so as to rest upon the posterior surface of the radius, 
without change in the relations of the several bones that constitute it, 
or with more or less separation of them from one another, the semi- 
lunar bone in two cases being completely detached from the others and 
remaining attached to the radius ; or the displacement may be complete 
only on the radial side, the movement being one of rotation (supina- 
tion) of the carpus turning on its inner side as a centre. A superficial 
transverse rent in the skin on the palmar surface of the wrist observed 
in one case was probably caused by overstretching of the skin across 
the projecting end of the radius. 

Symptoms. The deformity bears a close resemblance to that of Colles's 
fracture, but yet the differences are such that Albert 3 says he was able 
to make the differential diagnosis at sight. These differences are that 
the swelling on the anterior aspect of the wrist and lower part of the 
forearm extends further down, nearer to the hand, in dislocation than 
in fracture, reaching even to the ball of the thumb, and ends more 

1 Couteaud: Rev. de Chir., 1906, vol. 34, p. 193. 

2 Dupuy : Journ. de Bordeaux. July, 1850, quoted by Tillmauns. 

3 Albert: Chirurg., vol. ii. p. 440. 



DISLOCATIONS AT THE WRIST. 703 

abruptly ; that on the back of the wrist is more sharply outlined at its 
upper border. In addition, the hand and wrist are commonly more 
flexed upon the forearm and less movable in dislocation, and may be 
adducted. 

On palpation the styloid processes should be recognized, and their rela- 
tions to each other and to the bones of the hand and wrist determined ; 
in fracture the styloid process of the radius is displaced upward to or 
above the level of that of the ulna, its distance from the head of the 
second metacarpal bone, for instance, is unaltered ; while in dislocation 
the styloid process of the radius remains on a lower level than that of 
the ulna, and its distance from the head of the second metacarpal bone is 
lessened ; it is also further removed anteriorly from the back of the wrist. 

In some of the cases the upper margin of the dorsal swelling could 
be distinctly felt to be hard and rounded, the convexity directed upward 
and the bony thickness of the wrist to be notably increased antero- 
posteriorly, and movable upon the shaft of the radius. The anterior 
swelling is hard and irregular. 

Reduction has usually been easily effected by traction upon the hand 
and direct pressure on the carpus, and as a tendency to recurrence is 
not to be anticipated, no other dressings are needed than such as will 
secure immobility. 

In compound cases the treatment should be rigorously antiseptic, 
with ample provision for drainage. Many surgeons think that a par- 
tial excision in such cases favors recovery without accident, but I believe 
that opinion to be a survival from the pre-anti septic days, and that 
cleanliness, drainage, and rest will make excision unnecessary. 

The prognosis is favorable in the uncomplicated cases, and even 
when the dislocation has remained unreduced the re-establishment of 
the functions of the joint has been satisfactory. 

Dislocations Forward. 

The causes of the forward dislocations have commonly been a forci- 
ble bending of the hand forward or backward. In two cases it was 
direct violence ; in one of them, Moore, 1 the fall of a heavy weight 
upon the wrist while the latter was resting on the ground (the account 
does not state whether the forearm was resting on its anterior or pos- 
terior surface) ; in the other, Dieu, 2 the patient was kicked on the back 
of the hand by a horse. 

Pathology. Seven autopsies have been reported, Malle, 3 Letenneur, 4 
Collin, 5 Jarjavay, 6 Boinet, 7 Goodall, 8 and Dubar. 9 In addition, there 
is a compound dislocation, for which Bransby Cooper 10 amputated ; the 
position and extent of the wound are not stated, the only detail that is 

1 Moore: New York Medical Record, 1880, vol. xviii. p. 96. 

2 Dieu : Bull, de la Societe de Chirurgie, 1884, p. 296. 

3 Malle : Quoted by Malgaigne, Tillmanus, and Servier. 

4 Letenneur: Bull, de la Societe Anatomique, 1839, vol. xiv. p. 162. 

5 Collin : Ibid., 1844, p. 335. « Jarjavay : Ibid., 1861. p. 312. 

7 Boinet : Bull, de la Societe de Chirurgie, 1868, p. 211. This specimen was taken from 
the body of an old woman in the dissecting-room ; possibly the case was one of •spon- 
taneous " dislocation. 

8 Goodall : Lancet, 1878, vol. i. p. 937. 

9 Dubar; Gaz. des IIopit?uix, July 28, 1892. l0 Cooper : Loc. tit., p. 122. 



704 DISLOCATIONS. 

given being that " the flexor tendon of the thumb was torn through." 
These autopsies show rupture of the anterior and external lateral 
ligaments, and sometimes of all, the carpus being displaced well 
upward along the anterior aspect of the radius and ulna ; in one case, 
Goodall, the connection between the semilunar and cuneiform was 
destroyed, the latter bone retaining its normal relations with the trian- 
gular fibro-cartilage, while the scaphoid and semilunar with the rest 
of the carpus were displaced forward and upward, so that these two 
bones passed over the free torn border of the ligament stretching from 
the styloid process of the radius to the cuneiform, which was thus left 
interposed between them and the articular surface of the radius, and 
prevented complete reduction. Apparent reduction was easily effected 
during life, but the displacement at once recurred ; there were other 
wounds, and the patient died of tetanus on the eighth day. The ante- 
rior lip of the articular surface was broken off in two cases, and in 
one of these and another the styloid process of the radius was broken 
off. Fracture of the styloid process was observed clinically by Mal- 
gaigne, and fracture of the anterior lip was suspected in a case treated 
by me in 1882, because of crepitus perceived during reduction, and 
because of the facility with which the dislocation could be reduced and 
reproduced. Boinet says that in producing the dislocation upon the 
cadaver he always fractured the anterior lip of the radius. 

Symptoms. The hand may occupy any position between moderate 
dorsal and palmar flexion, the latter being the more common, and the 
fingers slightly flexed. Voluntary and passive movements of the wrist 
are restricted and painful. In a case reported by Roland, 1 a boy twelve 
years old, who had fallen five or six feet and struck upon the back of 
his flexed right hand, the wrist was immovable in right-angled flexion 
and the fingers were flexed into the palm and could not be straightened. 
During the struggles of etherization the bones snapped back into place; 
there was no tendency to recurrence, and the boy made a prompt recov- 
ery, using the hand freely in a few days. The deformity consists in a 
marked depression on the back of the wrist, the upper border of which 
is marked by the sharply projecting outline of the radius and the end 
of the ulna, and in a corresponding rounded prominence on the front 
of the wrist, formed by the displaced carpus. The hand appears to be 
shortened at the expense of the wrist, and an actual shortening can be 
demonstrated by measurement from the styloid process of the radius 
to the finger. The anteroposterior diameter of the wrist is increased. 

In the old cases (Collin, Jarjavay, Boinet) a new articular surface 
had formed on the anterior surface of the radius and ulna, in two of 
the cases a full inch above their lower ends. In Collin's the limb was 
equal in strength and freedom of use to the other, and all the move- 
ments were complete except those of abduction and adduction of the 
wrist, in which there was slight and greater loss respectively. 

Reduction has been easily effected, with or without anaesthesia, by 
traction upon the hand or by direct pressure on the displaced bones or 
by a combination of the two. In my case slight displacement forward 
persisted. 

1 Roland : Philadelphia Medical Times, 1879, vol. ix. p. 430. 



DISLOCATIONS AT THE WRIST, 705 

Dislocations Outward. 

Of this form of dislocation only one case has been reported., by 
Chapplain, 1 of Marseilles. The patient was a man, forty-seven years 
old, who had fallen from a height of four metres, the w r eight of his 
body being received upon his left hand. The hand was widely dis- 
placed to the outer side, and through a wound situated upon the inner 
side of the wrist the bones of the forearm projected and exposed their 
entire articular surface. The wound of the skin extended from the 
junction of the posterior and internal surfaces of the wrist, around 
the latter, and half-way across the anterior surface. The styloid pro- 
cess of the radius had been broken off, and it accompanied the carpus 
in its displacement. The pisiform was almost completely detached 
and crushed ; the connections of the semilunar with the carpal bones 
had been ruptured, and it preserved its relations with the radius. There 
was, in addition, a dislocation of the elbow backward. 

The fragments of the pisiform, the styloid process of the radius, and 
the semilunar were removed, and the dislocation easily reduced. A 
single suture was placed at the centre of the wound, and the hand and 
forearm were thickly enveloped in cotton firmly bound on (Guerin's 
dressing). A second dressing was applied on the eleventh day and 
removed on the twenty-second, when a large abscess was found on the 
back of the hand and forearm, and the wound made at the time of 
the accident nearly healed. A subsequent note, five and a half months 
after the injury was received, states that the wounds were all healed, 
the phalangeal and metacarpo-phalangeal joints had almost entirely 
regained their mobility, the wrist was completely anchylosed, and the 
elbow only slightly movable. 

Pathological Dislocations of the Radio-carpal Joint. 

These dislocations, so far as they are due to destructive disease of 
the joint, are of secondary interest, and do not readily lend themselves 
to a general description. Malgaigne quotes a few cases, generally 
reported briefly, of dislocations forward that have been slowly pro- 
duced in consequence of hydrarthrosis, arthritis, permanent contraction 
of the flexor muscles, and the retraction of cicatricial bands ; he refers 
also to two cases briefly mentioned by Guerin among his congenital 
dislocations, one in a child of six years, and the other in a girl of 
fourteen years with incomplete paralysis of the muscles of the fore- 
arm, in which the dislocation was backward and upward and backward 
and outward respectively. A more common form, one that has been 
seen with sufficient frequency to have received special study, is the 
following : 

Spontaneous Subluxation Forward. 

This affection was first described by Dupuytren 2 as a condition of 
the joint which might be mistaken for a dislocation, and of which he 

1 Chapplain : Bull, de la SociSte* de Chirurgie, 1874, p. 479, 
'-' Dupuytren ; CJinique Chirurgicale, vol. iv. p. 309. 

45 



706 DISLOCATIONS. 

had seen a considerable number of cases, especially in men whose 
occupations compelled them to make repeated, sudden, and violent 
traction with their hands, as in working a press or dressing cloth. He 
said that under the influence of these efforts the ligaments of the joint 
became stretched so that the bones were capable of more extensive 
change of place than was normal ; the carpus, being no longer held 
firmly against the bones of the forearm, yielded to the traction of the 
flexor muscles and shifted to a position in front of their lower ends. 
All the signs of a dislocation were present except pain and inflamma- 
tion. The more or less considerable deformity and weakness were the 
only inconveniences of the condition, and were not sufficient to cause 
the patients to intermit their work or seek medical help. Ordinarily 
the deformity could be reduced by traction, but it recurred as soon as 
the parts were left at rest. 

Malgaigne, referring to this description, says that he had for twenty 
years vainly sought an example of the condition in the largest press- 
rooms of Paris, and had met with only one, in a patient thirty-six 
years old, in whom the condition developed at about the age of twelve 
years apparently as the result of carrying heavy burdens ; in this case 
the carpus was displaced forward and upward, three centimetres above 
the lower end of the ulna, and one centimetre above that of the radius, 
the antero-posterior diameter of the wrist was five and a half centi- 
metres on the ulnar side, but could be reduced to four and a half cen- 
timetres by pressure, on the radial side it w T as only four centimetres, 
but the articular edge of the radius [posterior?] was much depressed 
and apparently inclined forward. Above the carpus, on the anterior 
surface of the radius, and apparently adherent to it, was a bony promi- 
nence. All movements were free, except dorsal flexion, which was 
notably diminished. 

In 1878 Madelung 1 read before the Seventh Congress of German 
Surgeons a paper upon the subject based upon the observation of 
twelve cases and the post-mortem examination of one. Of his twelve 
patients the dislocation was unilateral in ten (four on the right side, 
five on the left, and in one the side was not noted), and bilateral in 
two; eight patients were females, four males. The earliest age at 
which the condition originated was the thirteenth year; in only two 
cases did it begin after the twenty-third year. All but one of the 
patients belonged to the working class, but their occupations were not 
marked by great muscular efforts. The specimen was obtained from 
the body of a woman about twenty years old. The appearance of the 
limb was so typical that he was convinced of the correctness of the 
diagnosis of spontaneous subluxation, even in the absence of any history 
of the case. There was no sign of chronic inflammation of the bones of 
the arm or of any part of the skeleton. The limb was frozen and then 
sawn longitudinally in two places. The first section was made through 
the centre of the os magnum and its articulation with the semilunar, 
and divided the end of the radius so near its ulnar border that a por- 

1 Madelung : Deutsche Gesellschaft far Chirurgie, 1878, p. 259, and Archiv fur 
klinische Chirurgie, 1879, vol. xxiii. p. 395. See also Abadie, Revue d' Orthopedie, 
1903, No. 6. Benneke, Beilage zum Centralblatt far Chir., 1904, p. 157. Miiller: Ztl- 
blatt fur Chir., 1907, p. 1333. Franke : Deutsche Ztscht. fur Chir., vol. xcii. p. 156. 



DISLOCATIONS AT THE WRIST. 



707 



tion of the incisura semilunaris shows in the section. The second sec- 
tion divides the lower part of the ulna into two equal parts and passes 
through the cuneiform, pisiform, and unciform bones. The sections 
show that the radial side of the carpus is displaced about half an inch 
forward and an equal distance upward by the absorption of the anterior 
half of the lower end of the radius, the posterior half persisting like 
a malleolus extended over the dorsum of the wrist, and the displace- 
ment forward of the ulnar side of the carpus is much more marked. 
In Benneke's case the x-rays showed a similar condition. 

Fig. 323. 




Madelung's case of spontaneous dislocation of the carpus forward : longitudinal section 
through (C) the os magnum and {L) the semilunar. 

Fig. 324. 




§^i 




The same : longitudinal section through the ulna, (H) the unciform, and (T) the cuneiform. 



It seems probable that a case reported by Jean * as a double congen- 
ital dislocation forward was of this character. On the right side the 
cuneiform was placed well in front of the ulna ; the semilunar and 
scaphoid not so far in front of the radius, which had formed a new 
articular surface by loss of its anterior lip. In the left wrist the dis- 
placement was of the same character, but less marked. Possibly, also, 
Boinet's case, quoted above, page 703, and R. W. Smith's case 2 of sup- 
posed congenital dislocation belong to this class, and also one observed 
clinically and reported by Pooley 3 as a double congenital dislocation 
forward. 

1 .loan : Bull, de la Soek'te Anatomique, 1875, p. 398. 

2 K. W. Smith: Loc. cit., p. 251. 

3 Pooley : American Practitioner, 1880. vol. xxi. p. 216. 



708 DISLOCATIONS. 

The production of the deformity in the cases observed clinically was 
always gradual, requiring from six months to two years for its full 
development, and in no case could it be attributed to a traumatism, 
either slight or severe, and in no case were there any signs of acute or 
chronic inflammation of any part of the joint. In most cases the 
patients attributed it to continuous hard labor with the hands, but it did 
not appear that this labor was more than usually prolonged or hard. 
The women usually attributed it to washing clothes ; two of the men 
were farmers, one a tanner, and one a shoemaker. In the discussion 
that followed the reading of the paper Hirschberg said he had seen 
two clearly marked cases, the result of practice at the piano. The 
deformity in all the cases was accompanied by pain in the joint and 
was marked especially by the increasing prominence of the end of the 
ulna. After a time the pain ceased, the deformity remained stationary, 
and the freedom of use of the limb was unimpaired except by diminu- 
tion or total loss of dorsal flexion. 

After Madelung's attention had been called to the subject by obser- 
vation of his earlier cases, he took pains critically to examine the wrists 
of people in all classes of society, and was astonished to find how fre- 
quently he encountered slight deviations from the normal shape, all of 
which were of the type of spontaneous dislocation forward and were 
characterized not only by the abnormal projection of the end of the 
ulna but also by change in the articular surface of the radius and 
the position of the carpus. He attributed the more notable changes 
in the end of the radius found in the fully developed cases to the 
arrest of the growth of its anterior portion and to the overgrowth of 
its posterior portion stimulated by the loss of the opposing pressure 
normally exerted by the carpus, and he sees an analogy between this 
change and those observed in pes valgus and genu valgum. I have 
seen one case, a young lady who spent much time at the piano. Other 
cases have been recently reported by Schulze, 1 Sauer, 2 3 cases, Schade, 3 
and Putti. 4 

Estor, 5 who collected 85 cases, inclines to the theory of gradual de- 
velopment upon a congenital peculiarity, probably laxity of the lower 
radio-ulnar joint; in 36 of his 85 cases the condition was observed in 
more than one member of a family, and in 70 both wrists were affected. 
Siegrist 6 renews the rachitic theory of its origin. 

A reversed form has been described by Kirmisson 7 and by Stetter, 8 
2 cases. 

Symptoms. The most marked deformity is seen when the limb is 
viewed in profile from the ulnar side ; the end of the ulna projects 
markedly at the back of the wrist ; the hand is displaced toward the 
palmar side, and the antero-posterior diameter of the wrist is greatly 

1 Schulze : Munch, med. Wochenschrift, 1905, No. 30. 

2 Sauer : Beitrage zur klin. Chir., vol. xlviii, part 4. 

3 Schade : Ztlblatt fur Chir., 1906, p. 811. 
*Putti: Ibid., p. 1011. 

5 Estor : Revue de Chir., xxvii. Nos. 8 and 9. 

6 Siegrist: Deutsche Ztschft. fur Chir., vol. xcl. p. 524. 

' Kirmisson : Les difformities acquises de 1' appareil locomoteur, Paris, 1902. 
s Stetter: Ztlblatt fur Chir., 1908, p. 949. 



DISLOCATIONS AT THE WRIST. K) ( .) 

increased. Seen from the radial side the displacement forward does 
not appear so great, and the depression below the end of the radius is 
bridged over by the extensor tendons ; if these tendons are relaxed by 
dorsal flexion of the hand the posterior part of the articular surface of 
the radius can be traced with the finger, and its edge can be felt to be 
rounder than usual. In addition, the entire epiphysis appears to be 
bent forward. 

By traction and pressure the carpus can be brought nearer to the 
ulna, but it returns at once to its former place when the pressure is 
removed. No change can be effected in the relations of the carpus 
and radius. 

Sometimes the region is very painful ; points that are tender on 
pressure are seldom found, and usually only at the upper margin of 
the joint. Every movement of the joint, especially dorsal flexion, is 
very painful. 

Active and passive dorsal flexion is limited to an extent that corre- 
sponds to the degree of the subluxation, and in the most marked cases 
the hand cannot be carried backward beyond straight extension. The 
range of palmar flexion is more often increased than diminished, unless 
pain is present. 

Treatment. The alteration in the shape of the bones fully explains 
the failure of the few attempts that have been made forcibly to reduce 
the displacement, and the fact that the limb recovers nearly its full 
usefulness after the growth of the skeleton ceases and the progress of 
the displacement is arrested, furnishes a sound reason against operative 
interference. Prolonged attempts made by Madelung to improve the 
position by fixation in gypsum dressings and methodical manipulations 
did no good beyond relief of pain, and after he had learned the pathol- 
ogy and nature of the affection he limited his treatment to efforts to 
increase the strength of the arm in all its parts by methodical use and, 
in some cases, to the wearing of a moulded leather bracelet which could 
be tightened or loosened and was kept in place by a loop passing 
between the thumb and index-finger ; this prevented movements of 
the wrist and left the fingers free. In extreme cases osteotomy of the 
radius has been proposed. 

Congenital Dislocations of the Radio-carpal Joint. 

The question of congenital dislocation of the wrist is extremely diffi- 
cult and obscure, for in the great majority of the reported cases the 
history is so defective that the period at which the displacement took 
place must remain uncertain, although in most of them it was certainly 
during infancy or early childhood. In some the congenital origin of 
the malformation can hardly be called in question, because it is marked 
by great irregularities of shape and development extending over sev- 
eral bones and joints, but the propriety of classifying such eases as 
dislocations may well be questioned, for not only do the joint surfaces 
present hardly a trace of their normal form, but also one or more of 
the constituent bones may be entirely lacking. Such eases seem much 
more properly to belong among the "congenital malformations" and 



710 DISLOCATIOXS. 

to require classification as " club-hands " rather than as dislocations. 
In most of the reported cases in which the deformity has involved only 
the wrist the theory of congenital origin has been based upon the 
absence of the history of any traumatism that could account for the 
deformity, upon the statements of the patient or his friends that it had 
existed as long as they could remember, and upon its symmetrical 
occurrence in both wrists. The history of spontaneous dislocations 
forward shows how defective this argument is. 

The only alleged example of congenital dislocation which is accepted 
as such by Bouvier 1 and Malgaigne is one reported by Marigues in 
1755; it was observed in a stillborn child. The radius was widely 
separated from the ulna at its lower end, and in the interval between 
them w r ere lodged the bones of the first row of the carpus which were 
held in place by strong ligaments ; the hand was hooked inward, and 
it was held in this position especially by a strong ligament which 
extended from the second row of the carpus to the end of the radius. 

R. W. Smith 2 describes in detail several specimens of displacement 
and deformity which he deemed of congenital origin, and quotes a 
well-known case reported by Cruveilhier in the ninth livraison of his 
Anatomie Pathologique. One of these cases and two or three others 
which have also been reported as congenital have been mentioned in 
the preceding section. 

DISLOCATIONS OF THE CARPAL BONES. 

These present themselves as isolated dislocations of the individual 
bones or as partial or incomplete dislocations of the medio-carpal joint. 

Of the eight bones which form the carpus only the pisiform on the 
ulnar side and the trapezium on the radial side can be distinctly pal- 
pated. The former is felt as a small, hard lump at the junction of the 
palm and wrist close below the inner end of the lowest of the transverse 
creases that cross the wrist ; it rests upon the anterior face of the cunei- 
form bone. The trapezium can be readily grasped between the thumb 
and finger just above the base of the first metacarpal bone. A line 
drawn straight across the back of the wrist from one end to the other 
of the lowest transverse crease on the palmar surface crosses the neck 
of the os magnum directly above the base of the third metacarpal when 
the hand is extended in line with the forearm, and the finger can feel 
a distinct depression at this point, the upper margin of which is formed 
by the lower face of the semilunar ; if now the wrist is flexed forward 
the hollow becomes filled by a projecting piece of bone, the head of the 
os magnum. The medio-carpal joint is that between the three bones 
of the first row above and the four bones of the second row below. 

Medio-carpal Dislocations. 

Of these, one dislocation backward, verified by autopsy, and two 
forward, observed clinically, have been reported. Possibly some of 

1 Bouvier: Diet. Encyclopedique des Sc. Med., art. Main Bote, p. 166. 

2 R. W. Smith : Fractures and Dislocations, 1847, p. 238. 



DISLOCATIONS AT THE WRIST. 711 

the cases reported as dislocations of the os magnum were of this kind, 
and possibly there are intermediate forms between this and dislocation 
of the semilunar, for the latter is not infrequently accompanied in its 
displacement by a piece of the scaphoid and once by a piece of the 
cuneiform in a dislocation of the wrist in which it remained attached 
to the radius. 

A backward dislocation was reported by Maisonneuve ] in a patient 
who had fallen from a height of forty feet. The hand, displaced bodily 
to a plane posterior to that of the forearm, was shortened several lines ; 
behind, a few lines below the styloid processes, was a transverse bony 
prominence more than a centimetre high, with a depression below, 
opposite the transverse fold of the wrist. The fingers were flexed, and 
a considerable effort was required to extend them. The bones of the 
second row were completely separated from those of the first, and over- 
rode them posteriorly more than a centimetre. A small piece of the 
scaphoid remained attached to the trapezium, and a portion of the 
cuneiform, with the pisiform, accompanied the unciform. The internal 
and external lateral ligaments of the radio-carpal joint were completely 
ruptured, as were also the anterior and posterior ligaments uniting the 
two rows of the carpus. 

An incomplete dislocation forward was reported by Despres. 2 The 
patient was presented with his deformity to the Societe de Chirurgie, 
and as there was a difference of opinion concerning the nature of the 
lesion a committee was appointed to examine and report upon it ; they 
unanimously confirmed the diagnosis. The patient was a man twenty 
years old ; the injury Avas caused by a fall from a swing, probably upon 
the back, the hand being caught between the body and the ground. 
When he came to the hospital, a week later, there was no swelling or 
redness of the region ; on the back of the wrist, a finger-breadth below 
the edge of the radius, was a depression below which the wrist and 
hand had their normal appearance, and above which, between it and 
the radius, the finger recognized a distinct bony resistance. The axis 
of the hand was deviated outward. On the palmar surface the tendon 
of the palmaris longus and the thenar and hypothenar eminences were 
prominent. All the movements of the wrist were preserved, and only 
forced flexion was painful. Forced extension increased the displacement 
without notably changing the form of the palmar surface of the wrist. 
During flexion the prominence of the head of the os magnum was less 
apparent than in the other wrist ; the movement reduced the dislocation. 

The treatment consisted in maintaining the hand in the flexed posi- 
tion in which the bone returned to its place by means of a spiea ban- 
dage ; it was begun eleven days after the accident, and by the fourth 
day the pain had disappeared and the wrist had regained its form and 
functions. The bandage was worn a week longer. 

A complete dislocation forward has been reported by Richmond ; 3 the 
patient was a man, forty-seven years old, who fell upon his hand from 
a height of about nine feet, The hand, from the wrist to the knuckles, 

1 Maisonneuve : Mem. de la Soc. de Chir., quoted by Malgaigne. 

2 Desprds : Bull, de la Soc. de Chirurgie, 1875, vol. i. p. 412. 

3 Richmond : Lancet, 1879, vol. i. p. 844. 



7 1 2 DISL OCA TIOXS. 

was very noticeably shortened; there was a prominent transverse ridge 
on the back of the wrist below the ends of the radius and ulna, and 
below this ridge was a marked depression. On the palmar aspect the 
base of the hand was unduly prominent, the general direction of the 
metacarpal bones being quite altered by their bases being pushed for- 
ward toward the palm. Voluntary flexion and extension were lost. 
The ends of the radius and ulna seemed separated somewhat from each 
other ; the transverse dorsal ridge could be demonstrated to be the first 
row of carpal bones with the semilunar unduly prominent ; between it 
and the radius and ulna flexion and extension, although restricted, 
could be obtained with considerable ease and without crepitus. Xone 
of the carpo-metacarpal joints had sustained any injury. On the pal- 
mar prominence the trapezoid could be felt placed more anteriorly than, 
and considerably above, the level of the trapezium ; and nearer the 
ulnar side the head of the os magnum could be felt slightly overlapping 
the ends of the radius and ulna, which on the palmar surface were 
quite obscured; and on flexion and extension of the hand the os mag- 
num could be felt to ride on their anterior surface. The displacement 
of the unciform, although distinct, was much less marked. 

Midcarpal Fracture -dislocation. x 

Under this title is described an injury of which the typical features 
are fracture of the scaphoid, dislocation forward of the semilunar and 
the proximal fragment of the scaphoid, and more or less derangement 
of the relations of the os magnum with the adjoining bones. De Quervain 
termed it " Dislocation-fracture of the Carpal Bones " or " of the inter- 
carpal joint," and Delbet " Dislocation of the Os Magnum/' with sub- 
titles indicating variations. The title at the head of this section seems 
to me to be preferable to^either and is practically the same as that used 
by Schoch. 

The first known example was found by Fugue 2 at autopsy in 1887 ; 
then ten years later a few cases were disclosed by the .r-rays, and in 
1901 De Quervain, having treated a case in which both wrists were 
similarly injured, was led by the identical features of the two lesions 
to suspect that they might represent a class and to study the subject 
with the aid of such cases as he could find reported. Since then many 
cases have been reported, especially from the Zander institutes, and two 
papers dealing with the subject in great detail have been published by 
Schoch and Delbet. The former contains a large bibliography, and the 
latter the results of much experimentation. 

The injury, while infrequent, is not rare. It occurs almost exclus- 
ively in males, doubtless because of their greater exposure to accidents, 
and between the ages of twenty and forty years. The common cause is 

1 De Quervain : Monatschrift fur Unfallheilkunde, 1902, vol. ix. p. 65. Wolff: Ibid, 
vol. x. Schoch : Beitrage zur klin. Chirurgie, 1907-8, vol. xci. p. 53. Delbet : Bull, et 
Mem. de la Soc. de Chirurgie, 1908, vol. xxxiv. p. 377. Lilienfeld : Zeitschrift fur 
Orthop. Chir., 1908, vol. xx. p. 437. See also several of the later references given in 
the bibliography^of Fractures of the Carpal Bones and Dislocation of the Semilunar. 

2 Gaz. hebdom. de Montpellier, 1887, vol. ix. No. 1. 



PLATE LV 





Midearpal Fracture-dislocation. 



PLATE LVI 




Midearpal Fracture-dislocation by Volar Flexion. 



PLATE LVII 




Midcarpal Fracture-dislocation. Same ease as Plate LV. 



PLATE LVIII 




Midcarpal Fracture -dislocation. 



PLATE LIX 




Midearpal Fracture-dislocation, after removal of proximal 
fragment of scaphoid. 



PLATE LX 





M idea r pal Fracture-dislocation. 



DISLOCATIONS AT THE WRIST. 713 

violence received on the ball of the dorsally-flexed hand in a foil. In 
three or four cases (one my own, Plates XL VI and XLVIJj the cause 
appeared to be forced volar flexion. In circumstances so different the 
mechanism cannot be the same, but in the common form, dorsal flexion, 
the dislocating pressure appears to be applied through the head of the 
os magnum to the semilunar. The volar ligament connecting the 
semilunar and os magnum yields while that connecting the anterior lip 
of the radius and the semilunar remains untorn ; the semilunar slips 
forward, with rotation about its transverse axis, and takes with it the 
proximal portion of the scaphoid (See also Chapter XXI., Fractures of 
the Carpal Bones). The semilunar may even pass upward, above the 
edge of the radius. In only one reported case (Sulzberger) has the 
cuneiform accompanied the semilunar. The regularity of this separa- 
tion of the semilunar and adjoining portion of the scaphoid, and its 
occurrence under different forms of violence suggests an anatomical or 
anatomo-mechanical structure of the carpus favoring it which is further 
supported by an interesting observation which I reported in 1891 to 
the New York Surgical Society, the same pieces were separated from 
the carpus but remained attached to the radius, the rest of the carpus 
being dislocated from them and it ; several similar cases have been re- 
ported. Schoch thinks that the cuneiform and the distal portion of 
the scaphoid may be considered as portions of the second row of carpal 
bones rather than of the first because of their stronger ligamentous at- 
tachments to it. 

Delbet's experiments showed that when the injury was produced by 
extreme dorsal flexion fracture of the scaphoid was the first to occur, 
and that if the movement was then arrested the volar ligaments were 
found untorn. He found also that if the movement was continued a 
little further the head of the os magnum stripped the dorsal ligament 
from the posterior pole of the semilunar, and that if the movement was 
then arrested the head of the os magnum would rest in dorsal dislo- 
cation upon the back of the semilunar, whence it could be easily re- 
placed again, leaving only the fracture of the scaphoid to be recognized 
clinically. This is apparently one of his reasons for including isolated 
fracture of the scaphoid in the larger group. 

Additional force pressing the carpus directly or obliquely toward 
the radius and forcing the semilunar forward from its place is necessary 
to the production of the typical complete form. 

The semilunar and proximal fragment having been displaced forward 
from the radius, the head of the os magnum passes into the gap thus 
created and approaches the inferior surface of the radius. 

According as the semilunar is displaced more or less forward, the 
os magnum is in liue with the radius or displaced backward from it. 
The different positions of these bones are shown in the series of plates 
(LV-LX). 

Three associated lesions occur frequently enough to be deemed ex- 
treme additions to the type : fracture of the styloid processes of the radius 



714 



DISLOCATIONS. 



and ulna, and Colles's fracture. Others — fracture of the cuneiform and 
of the os magnum, and mutual crushing of the os magnum and unci- 
form — probably depend upon variations in the degree and continuation of 
the force. So also with such cases as mine of 1 8 9 1 , above mentioned, and 
one or two similar ones in which the end of the radius projected through 
the skin, in which the semilunar and fragment of the scaphoid preserved 
their relations with the radius, the direction of the violence was up- 
ward and backward instead of upward and forward. Also fracture of 
the palmar or dorsal edge of the articular surface of the radius has 
been seen. 

The symptoms are fairly characteristic. Function is lost because of 
pain ; the fingers are flexed and an attempt to straighten them causes pain 

Fig. 325. 




Midcarpal fracture-dislocation. 8L, semilunar. S' S," broken scaphoid. Styloid 
process of radius broken. Tracing from steroscopic skiagram. The shading represents 
the deeper (dorsal) levels. (Schoch). 

because of pressure of the tendons on the displaced and broken bones 
and on the median nerve. The hand is slightly shifted to the radial 
side, and the end of the ulna is consequently prominent. The wrist is 
slightly shortened by the approximation of the os magnum to the radius, 
and its antero-posterior diameter is increased by the dislocation forward 
of the semilunar and fragment of the scaphoid, which can be felt as a 
hard, perhaps movable, prominence or as increased resistance beneath 
the flexor tendons. The broad, thick extensor tendons interfere with 



DISLOCATIONS AT THE WRIST. lib 

palpation of the dorsum but sometimes a gap can be felt below the dorsal 
vdgv of the radius. The hand may be abnormally movable in both 
planes upon the forearm. 

The differential diagnosis from the commoner injuries of the region — 
sprain, Collcs's fracture, and fracture of the scaphoid — should not be 
difficult, for the shortening of the wrist, the palmar prominence of the 
bones, and the outward shift of the hand are not found in them. 
From isolated dislocation of the semilunar it may well be difficult, for 




Midcarpal fracture-dislocation after removal of semilunar and fragment 
of scaphoid. (Schoch.) 

there is the same palmar prominence, and the absence of shortening 
and lateral shift may be made uncertain by the swelling. Insensitive- 
ness on pressure in the tabatiere (fracture of scaphoid) might help. 
Sensitiveness on pressure over either styloid process would point to 
fracture-dislocation. Medio-carpal dislocation is rare and would have 
to be recognized by tracing the upper edge of the projecting row. If 
the .T-rays are used lateral and antero-posterior views should be taken. 

If the displacement is uncorrected the patient remains long disabled, 
as time passes the pain and sensitiveness may diminish and disappear 
and the hand regain a considerable measure of usefulness, but the 
motions of the wrist will be much restricted and the strength of the 
grip lessened. In the one case in which reduction was effected there 
was some loss of mobility in the wrist. When a chronic arthritis en- 
sues all motion at the wrist may be lost. 

The choice of treatment, to be determined by the extent of the lesions 
and the possibilities, lies between simple reduction, operative reduction, 



716 DISLOCATIONS. 

and extirpation of one or more of the bones. If reduction fails and 
operation is rejected, the wrist ninst be immobilized with the fingers free, 
and massage and moderate passive motion used after a week or two. 

For simple reduction strong traction should be made on the hand to 
recreate the gap between radius and os magnum, perhaps with full 
dorsal flexion as recommended by Codman in dislocation of the semi- 
lunar alone, pressure from the palmar side to force the semilunar back 
into place, and then palmar flexion. This latter position should be 
maintained by the dressing, and Schoch advises that an .T-ray plate 
should be made after the application of the dressing to detect a re- 
newal of the dislocation if it should have taken place. The histories 
show that in most of the cases (including probably some of the semi- 
lunar alone) the reduction proved not to have been complete or to have 
recurred. 

Operative reduction, successful in one case, gave a result that was not 
very satisfactory in respect of function. The operation of choice ap- 
pears to be the early removal of the semilunar and the proximal fragment 
of the scaphoid, by an incision alongside the tendon of the palmaris 
longus. Delbet recommends the removal of the semilunar even in 
those cases in which it has preserved its relations with the radius. The 
results thus far have been more satisfactory than those obtained by 
other methods. It is also supported by recent experience with fractures 
of the scaphoid (q. v.). 

Isolated Dislocation of the Different Bones of the Carpus. 

This is a very rare injury except in the case of the semilunar, yet 
instances have been reported of the dislocation of almost every one of 
them. Eigenbrodt 1 has made a large, though somewhat uncritical, 
collection of reported cases. See also Sulzberger. 2 

Scaphoid. The reported cases of dislocation of the unbroken scaphoid 
number about ten, and in some of these the accuracy of the diagnosis 
may perhaps be questioned. One in which the diagnosis was con- 
firmed by arthrotomy was reported by King. 4 In most the dislocation 
was backward, and in two reduction was made by direct pressure. 
For dislocation of a portion of the bone, see Fracture of the Scaphoid 
and Dislocation of the Semilunar. 

A supposed case of backward dislocation was observed at the Hudson 
Street Hospital in 1899. The injury was an old one, the patient 
applying for some other affection. The lesion was carefully examined 
by two members of the house-staff, who concurred in the diagnosis. In 
Nov., 1904, 1 saw a case there in which both scaphoids had been partly 
displaced backward at the central end. There was so little pain and 
swelling that I doubted the recent traumatic character of the condition, 
but the patient insisted that it was new and caused by forced palmar 

1 Eigenbrodt: Beitrage zur klin. Chir., 1901, vol. xxx. p. 305. 

2 Sulzberger : Fortschritte ans dem Geb. der Roentgenstrahlen, 1901-2, vol. v. p. 5. 

3 For cases and references see Eigenbrodt. 
* King : Annals of Surgery, August, 1899. 



DISLOCATIONS OF CARPAL BONES. Ill 

flexion. The displacement was irreducible and the interference with 
function slight. The arrays confirmed the diagnosis. 

Another case has been recently reported by Senechal : ; the injury 
had existed fifteen years and flexion and extension limited one-half. 
The proximal end of the bone projected on the dorsum on the inner 
side of the tendon of the long extensor of the thumb. The pro- 
jecting portion was chiseled away, with improvement in function. 
Riedl 2 reports a forward dislocation by a fall, easily reduced by 
pressure. 

A case of dislocation forward of the scaphoid complicating fracture 
of the lower end of the radius, in which the bone was removed through 
an incision, was reported by Cameron. 3 Six years later he 4 again 
reported the case, this time as one of dislocation of the semilunar 
bone, but made no mention or explanation of the previous statement 
concerning it, although he described the case in the same terms as 
before. 

Semilunar. 5 In the last few years the arrays have shown that dislo- 
cation of the semilunar bone, either alone or in combination with frac- 
ture of the scaphoid or with disturbance of the relations of other carpal 
bones, is far from uncommon and is second in order of frequency to 
fracture of the scaphoid. See also preceding section Midcarpal Frac- 
ture-dislocation. 

The displacement is always forward with rotation on the transverse 
axis. In Erichsen's case of alleged backward dislocation the identity 
of the displaced bone was not positively determined. The bone lies 
beneath the flexor tendons opposite its site or a little higher on the 
radius, and in the extreme cases it may slip past the tendons and make 
the dislocation compound by rupture of the overlying skin. 

It is habitually produced by dorsal flexion of the wrist, and while 
the mode of production is still in dispute von Lesser's explanation 
appears to be the most plausible. He describes three stages, supported 
by clinical evidence and skiagrams (Fig. 316). In the first, during 
dorsal flexion, the palmar apex of the bone is fixed by the strong 
palmar ligaments and the dorsal apex presses against the head of the 
os magnum (stage of subluxation). Then the dorsal apex slides along 
the head into the gap between the scaphoid and os magnum and reaches 

1 Senechal: Gaz. des Hop., 1906, p. 1515. 

2 Riedl : Wiener klin. Wochenschrift, 1906, p. 1520. 

3 Cameron : Glasgow Medical Journal, 1878. 
+ Ibid : Lancet, 1884, vol. i. p. 885. 

5 The references are: Mougeot, quoted by Malgaigne; Flower and Hulke, Holmes's- 
System of Surgery, Am. ed„ vol. i. p. 881; Erichsen, Science and Art of Surgery, 
Am.ed., 1873, vol. i. p. 421; Taafe, British Medical Journal, 1869, vol. i. p. 335, Chis. 
olm, Philadelphia Medical Times, 1870-71, vol. i. p. 335 ; Gross, Philadelphia Medical 
Times, 1880-81, vol. xii.p.220; Buchanan, Medical Times and Gazette, 1SS5, vol. i. p. 
113 ; Forgue, Gaz. hebdom. de Montpellier, 1887, vol. ix. No. 1 ; Albertin La Province 
Medic ale, 1887, p. 420, and a second case in Lyon Medical, December 9, 1894 ; Gamgee, 
Lancet, July 6, 1895; Stimson, New York Medical Journal, January 3, 1S91, p. 20; a 
second case in Annals of Surgery, March. 1898, p. 265; Bolton, Ibid., August, 1901. p. 
291 ; Richon, Arch, de Med. et Pharm. Mil., 1903, No. 3 ; Steffel, Arch, fur klin. Chir., 
vol. lxm. Part I.; v. Lesser, Deutsche Zeitschrift fur Chir., 1902. vol lxvii. p. 488; 
Wittek, Arch, fiir klin. Chir., 1904, vol. xlii. p. 578; Wendt, Munch Med. Wochen- 
schrift, 1904, No. 24; Codman and Chase, Annals of Surg., June, 1905; Hildebrandt, 
Berl.klin. Wochenschrift, 1905, p. 935; Lilienfeld, Arch, fur klin. Chir.. vol. lxxvi. p. 
641; Montaudon, Beitrage zur klin. Chir., vol. lvii. p. 9. See also Eigenbrodt 



718 



DISLOCATIONS. 



the palmar side of the carpus (complete dislocation), its lower concave 
surface directed forward ; the bone may lie opposite its normal position 
or higher up on the radius. In the third stage the rotation may increase 
to 180°. It is interesting to note in this connection that in two of 
Couteaud's cases of compound dislocation of the wrist the semilunar 
remained attached to the radius and was once accompanied by a piece 
of the cuneiform. The palmar ligment uniting the radius and semi- 
lunar usually remains untorn ; that uniting the semilunar and os mag- 
num is torn. 

Pressure upon the tendons may keep the fingers partly flexed, and 
there may be numbness or pain in the distribution of the median nerve. 

The diagnosis is made by recognition of the bone under the flexor 
tendons and of the gap on the dorsum between the os magnum and 

radius. 

Fig. 327. 

/ 





1. 2. 3. 

Three stages of dislocation of the semilunar, (v. Lessen.) 

In some uncomplicated cases reduction has apparently been affected 
by manipulation, but in a number of them (Codman, Hildebrandt) 
later examination showed that reduction had been incomplete or that 
the displacement had recurred. It is, I think, evident that the sur- 
geon cannot be certain that he has fully reduced or that the bone will 
remain in place, and as removal of the bone has given as good func- 
tional results as reduction has, the surgeon is justified, I think, in 
resorting to removal at once. Nevertheless, late removal seems to 
give equally good results. In compound cases immediate removal is 
indicated. Only 1 successfully reduced by operation forty-five days 
after injury. 

For reduction Codman recommends that the wrist should be hyper- 
extended, the bone pushed into place and held there with the thumbs 
while the wrist is flexed. 



1 Only : Deutsche Zeitschrift fur Chir., vol. xciii. p. 218. 



PLATE LXI 




Fig. 1.— Old Dislocation Backward of the Os Magnum. 




Fig. 2.— Same as Fig. 1. 



DISLOCATIONS OF CARPAL BONES. 719 

Unciform. There are three recorded cases. One is very briefly re- 
ported by Buchanan 1 : a man fell from a railway car ; "he was found 
to have a simple luxation of the unciform bone anteriorly. It lay just 
beneath the skin, and its process could be distinctly outlined. Reduc- 
tion was effected by direct pressure on the bone while the borders of 
the hand were approximated." Another is reported by Eigenbrodt. He 
excised the bone ; the process had been broken off. In the third 2 the 
hand had been crushed in a machine, with a ragged wound on the 
thenar eminence. The a?-ray showed the unciform freed from all its 
attachments and displaced forward. No attempt to reduce. Seven 
months later flexion of the wrist was restricted, the fingers could not 
be fully closed, but the man was at work. 

Pisiform. The pisiform has been reported dislocated in five cases : 
in two (Erichsen, Fergusson) by muscular effort ; in one (Gras 3 ) by the 
pressure of the hand upon a flat-iron while ironing clothes. In Erich- 
sen's case the bone was drawn up the arm for a distance of nearly an 
inch. Doubtless the displacement was the result of rupture of the 
tendon below the bone. 

Os Magnum. Many authors speak of partial dislocation of the head 
of the os magnum backward as a not infrequent accident produced by 
prolonged, perhaps not violent, use of the hand, or by a sudden effort, 
or a fall. Malgaigne classifies the former as pathological dislocations ; 
they are characterized by the appearance on the back of the wrist just 
above the base of the third metacarpal bone of a small, hard, round 
lump, especially during palmar flexion, which disappears more or less 
completely during dorsal flexion, and can sometimes be temporarily 
reduced by pressure. It ordinarily causes little or no disability. 

The more distinctly traumatic cases are those of Richerand (quoted 
by Cooper 4 ) and Seeger (quoted by Tillmanns). Richerand's patient 
was a woman who grasped the side of her bed during parturition, turn- 
ing her wrist forward, and felt a sharp pain in the wrist. A fortnight 
later, a hard, circumscribed tumor was found at the back of the carpus, 
formed by the head of the os magnum, which was readily replaced by 
making gentle pressure on it, and extending the hand. Richerand 
had seen another similar case, as had also Chopart and Boyer. 

Cooper's patient was a young, muscular man, who had fallen upon 
his hand in such a way as to bring the palmar aspect of the fingers 
into contact with the forearm. At the point of most pain was a round, 
hard tumor, rather larger than a marble, which produced a most evi- 
dent deformity on the back of the wrist opposite to and above the base 
of the third metacarpal. The hand was slightly bent, and extension 
caused considerable pain ; the tendon of the extensor carpi radialis 
brevior was displaced slightly to the radial side ; the forefinger was 
abducted from the middle one, and any attempt to approximate them 
gave great pain at the base of their metacarpal bones ; and opposite 
the base of the middle one was a depression, quite evident to both sight 

1 Buchanan : Philadelphia Medical and Surgical Reporter, 18S1-82, vol. xlvi. p. 41S. 

2 Ebermayer: Fortschritte aus dem Geb. der Roentgenstrahlen, 1908, vol. xii. p 1. 
:i Gras: Gazette Medicale, 1835, p. 542. ' Cooper: Loc. cit. p. 434. 



720 DISLOCATIONS. 

and touch. Reduction was effected by making traction on the fore and 
middle fingers, while pressure was made upon the os magnum. On 
flexing the hand the deformity was reproduced ; it was again corrected, 
and the hand placed in splints. 

Seeger 1 saw in 1829 and 1830 two cases of dislocation of the head 
of the os magnum backward caused in young men by falls upon the 
closed fist. Reduction was effected by traction and forcible flexion of 
the hand, in one case easily, in the other only after several attempts. 
The hand was kept in splints in the extended position from six to eight 
weeks, with compresses in front and behind. Recovery was complete. 

The only case of total dislocation of the bone of which I know was 
in a patient who applied at the Hudson Street Hospital in 1899 
because of another injury. A lump was noticed at the back of his 
wrist, which he said dated from an injury received nine years before. 
Two skiagrams, taken at the time (Plate LXL), clearly show the 
three bones of the first row in place and the projection of the dislocated 
bone over the site of the os magnum. There was no loss of function. 

Trapezoid. The diagnosis of dislocation of the trapezoid backward 
was made in a case reported by Gay ; 2 the patient was a man, thirty- 
two years old, and the injury was caused by striking with the fist in 
play. " At the base of the metacarpal bone of the index-finger was a 
sharp, hard, slightly movable bunch, raised one-quarter of an inch, 
and tender on pressure." There was no crepitus ; the metacarpal 
bones were of the same length. It could not be reduced. Two 
months later the deformity was unchanged, but the hand had become 
nearly as good as the other. Sheldon 3 reports an almost identical case. 

Trapezium. Two cases of dislocation backward of the trapezium 
alone have been reported by Uhde 4 and von Mosengeil. 5 

Uhde's patient was a man, thirty-three years old, who had been 
knocked down by a wagon. The right thumb and the region of its 
metacarpal bone was bruised, swollen, and painful, and "at the 
junction of the first metacarpal and trapezium an unusual mobility 
of the latter bone was recognizable, and instead of the normal depres- 
sion between the tendons of the extensor secundi and extensor primi 
internodii on extension of the hand there was to be seen a small 
angular tumor corresponding to the trapezium, which projected on 
flexion of the first and second metacarpals about three and a half lines 
above the level of the back of the hand, and disappeared on straight 
extension of these bones with a creaking sound. Six months later the 
trapezium was found to project one and a half lines on the radial side.' 7 

Von MosengeiPs patient had a deformed hand, the thumb and its 
metacarpal bone having the shape and position of a finger ; the dis- 
placement, half a centimetre, was produced by a blow received upon 
the palm of the hand ; it was reduced by flexion and pressure. 

There is one case in the records of the out-patient department of the 

1 Seeger . Mittheilungen der Wiirtt. arztl, Vereins, vol. i., quoted by Tillmanns. 

2 Gay : Boston Medical and Surgical Journal, 1869, vol. lxxxi. p. 188. 

3 Sheldon : American Journal Medical Science, January, 1901. 

4 Uhde : Deutsche Klinik, 1850, vol. ii. p. 539. 

5 von Mosengeil: Arch, furklin. Chirurgie, 1871, vol. xii. p. 723. 



DISLOCATIONS OF CARPAL BONES. 721 

Hudson Street Hospital. It did not come under my observation, and 
the details are lacking in the report. 

Os Magnum Trapezoid. Uhde 1 briefly describes, under the title 
"luxatio ossis multanguli minoris et ossis capitati," a case of injury to 
the wrist marked by a projection on the back of the hand, which he 
attributed to the displacement of the trapezoid and os magnum. The 
injury was caused by a fall upon the " anterior ends of the metacarpal 
bones." It does not appear from the description whether the bones 
were thought to be dislocated from the metacarpals as well as from the 
first row of the carpus. The prominence could be reduced by pressure, 
and reappeared on flexion of the wrist. 

A case reported by Alquie, of Montpellier, has been frequently 
quoted ; there was much displacement of the carpal bones on the radial 
side, but not only was its character uncertain, but in addition the region 
had suffered from two different accidents, one of which was accompa- 
nied by great laceration of the soft parts. 

CARPOMETACARPAL DISLOCATIONS. 

Cases have been reported of the isolated dislocation of every one of 
the metacarpal bones except the fifth, and of the combined dislocation 
of two or more. 

First Metacarpal. Dislocations of the metacarpal bone of the thumb 
are the most frequent and important ; almost all have been back- 
ward. 

Very little is known of dislocations forward. Sir Astley Cooper 2 
says, " In the cases which I have seen of this accident the metacarpal 
bone has been thrown inward, between the trapezium and the root of 
the metacarpal bone supporting the index-finger ; it forms a protuber- 
ance toward the palm of the hand ; the thumb is bent backward and 
cannot be brought toward the little finger." Poinsot quotes a reference 
by Vidal de Cassis to a case of incomplete dislocation forward which 
he had easily reduced. 

Albert 3 saw two cases of incomplete dislocation outward; one was 
old, the other recent. In the latter the injury was produced in a trial 
of strength by grasping hands. The displacement was easily reduced, 
but immediately recurred. After reduction the thumb was fixed in 
abduction by a silicate dressing and so maintained for six weeks. 
Complete recovery. 

Dislocations backward may be complete or incomplete ; the former 
are infrequent, the latter quite common. Of the 73 cases of metacarpal 
dislocation in my statistics (Chapter XXVII.) almost all were of this 
bone and of this kind. The cause may be a forced flexion of the 
thumb into the palm of the hand, or its forced movement in the oppo- 
site direction, or direct violence received upon the thenar eminence, 
as in striking upon the handle of a chisel, or in striking a blow with 
a hammer, or in the bursting of a gun. 

Specimens of old dislocation have been dissected by Foucher 4 and 

1 Uhde : Loc. cit. 

2 Cooper : Loc. cit., p. 443. :! Albert: Chinxrgie, vol. ii. p. 445. 
* Foucher : Bull, de la Soc. Anatomique, 1856, p. 6. 

46 



722 DISLOCATIONS. 

Gerin-Roze ; 1 in the former the upper end of the metecarpal bone was 
displaced backward and a little inward, and was flexed at a right angle 
to and fused with the trapezium ; in addition, the second metacarpal 
was displaced upward about two centimetres on the back of the wrist, 
retaining the insertion of the extensor carpi radialis, and the third 
metacarpal had been broken at its middle. The injury was caused by 
the bursting of a gun. In Gerin-Roze's case the displacement was 
directly backward, the anterior edge of the base of the metacarpal rest- 
ing upon the posterior edge of the inferior articular surface of the 
trapezium ; incomplete reduction could be made. 

In the incomplete form the posterior edge of the base of the meta- 
carpal bone can be seen and felt in the interval between the tendons of 
the extensor primi and extensor secundi internodii as a hard lump 
continuous with the shaft of the bone and reducible by pressure. The 
thumb is generally somewhat flexed toward the palm, but may be 
extended or "straight." Movement is limited and painful, and flex- 
ion increases the apparent displacement. 

In the complete form the dorsal prominence is more distinct, and 
rests upon the trapezium which forms a recognizable lump in the ball 
of the thumb. The thumb is shortened by the ascent of the meta- 
carpal bone, its first phalanx appearing in consequence to have passed 
upward into the thenar muscles, and it is usually flexed at the carpo- 
metacarpal joint. 

In some, even recent, cases reduction has been impossible, but usually 
it has been effected without difficulty by traction on the thumb and 
direct pressure forward and downward upon the projecting end of the 
bone. Early recurrence has been noted in some cases, and in a few 
prevention of recurrence has been difficult or incomplete. Moulded 
splints of leather, plaster, or gutta-percha, and pasteboard or wooden 
splints with compresses at the back of the joint are ordinarily used, and 
have given satisfactory results. In one case the only dressing con- 
sisted of strips of adhesive plaster, running from the back of the forearm 
around the ball of the thumb, and back between it and the index-finger 
to the forearm, so as to maintain the member abducted and extended. 

The restoration of function after reduction is complete, and even 
when the dislocation has remained unreduced some patients have been 
able to make good use of the thumb ; in others the movement of 
adduction and opposition has been much restricted. 

The second metacarpal has been reported dislocated forward in two 
cases and backward in six cases ; in one of the latter together with 
dislocation of the first, and in another with dislocation of the third. 
An additional case, observed by himself, is mentioned by Demarquay, 2 
in which the first and second were together dislocated, but the direction 
is not stated, and no details are given. 

The forward cases are those of Bourget (quoted by Malgaigne) and 
Marsh (quoted by Hamilton). In Bourget' s, the cause was excessive 
pressure on the upper posterior part of the bone ; in Marsh's, it was 
an oblique blow with a hammer on the back of the clenched hand. In 

1 Gerin-Roze : Bull, de la Soc. Anatomique, 1858, p. 266. 

2 Damarquay : Bull, de la Societe de Chirurgie, 1851, vol. ii. p. 171. 



CABPO-METACARPAL DISLOCATIONS. 723 

both cases the proximal end of the bone could be felt in the palm, and 
a corresponding depression on the back ; in the former case the lower 
end of the bone was inclined forward, and the finger appeared short- 
ened nearly one-fourth of an inch. Both were easily reduced by trac- 
tion on the finger and pressure on the end of the bone. 

The uncomplicated backward cases are those of Hamilton, 1 Hum- 
bert, 2 and Lyman 3 ; the former was caused in a woman, twenty-eight 
years old, by a fall upon the closed hand. Reduction was easily 
effected. Humbert's patient was a man thirty years old, who was 
kicked by a horse upon the hand that held the reins, the blow falling 
on the back of the lower end of the second metacarpal bone and the 
adjoining phalanx ; the upper end of the bone could be felt as a hard, 
circumscribed prominence on the back of the hand, and the finger, 
measured by the adjoining one, appeared five millimetres short. Re- 
duction was made by traction and direct pressure downward and for- 
ward. Lyman had to incise and pry the bone into place. 

The case in which the dislocation was associated with that of the 
first metacarpal is that of Foucher, mentioned above. 

In two cases seen by Hamilton there was incomplete dislocation back- 
ward of the upper end of the second and third metacarpals, caused by 
striking a blow with the fist ; in both cases the dislocation was old, and 
had persisted in spite of attempts to maintain reduction. 

Third Metacarpal. In addition to these two cases, in which the injury 
was associated with dislocation of the second metacarpal, dislocation 
backward of the third metacarpal has been reported by Blandin 4 and 
Roux. 5 Blandin's patient fell, while holding a roll of paper, and 
struck his hand against a post ; the blow was slight, and caused no 
pain at the time, but the middle finger promptly became powerless, 
and the hand numb and swollen. There was a linear transverse ecchy- 
mosis at the back of the first phalanx of the middle finger, close by 
the metacarpal joint, and, on movement, a crackling that resembled 
crepitus. No other symptoms are mentioned. Blandin made the diag- 
nosis of " diastasis or incomplete dislocation " of the third metacarpal 
bone, but others who saw the case thought the bone was broken. The 
title of the report of the case is " incomplete dislocation upward." 

Roux's patient had been injured in a mine explosion ; a hard, cir- 
cumscribed, subcutaneous tumor could be seen and felt on the back of 
the wrist, continuous and moving with the third metacarpal ; the middle 
finger was shortened. The dislocation was reduced by direct pressure, 
but appears to have recurred, for at the autopsy the base of the bone 
was found resting on the back of the os magnum ; the second meta- 
carpal was broken. 

Fourth Metacarpal. An incomplete backward dislocation of the 
fourth metacarpal was reported by Maurice. 6 It was caused by the 
premature explosion of a cartridge which the patient Avas putting 
into a Chassepot gun ; the plunger was driven backward against the 

1 Hamilton : Loc. cit., p. 724. 2 Humbert : Union Medicale, 1S6S, vol. v. p. 527. 

:! Lyman: Annals of Surg., June, 1906. 

1 Blandin : Gazette des Hopitaux, 1844, p. 552. 

5 Roux: Union Medicale, 1848, p. 224. 6 Maurice: Gazette Medicale, IStiS. p. 587. 



724 DISLOCATIONS. 

palm of the hand. There was a prominence half a centimetre high 
on the back of the hand, corresponding to the upper end of the fourth 
metacarpal. Reduction was easy, and recovery prompt. 

The four inner metacarpal bones (II., III., IV., V.) have been simul- 
taneously displaced in four cases, Yigouroux, 1 Hamilton, 2 Tillaux, 3 and 
one of my own ; in the first and second the dislocation was backward, 
in the others forward. 

Yigouroux's patient was injured, when eighteen years old, by the 
explosion of a pistol which he held in his left hand. At his death, at 
the age of sixty-two years, there was found a complete dislocation 
backward of the last four metacarpal bones ; these bones were flexed 
forward and the proximal phalanx of each of the last three fingers was 
incompletely dislocated backward. The index-finger and the lower 
part of its metacarpal bone were lacking. All the joints of the carpus, 
including that of the trapezium and first metacarpal, were normal. 

Hamilton's patient was struck by a bullet which entered at the ulnar 
side of the hand and crossed the back of the wrist between the last row 
of carpal bones and the skin. When seen by Hamilton five years later 
"the displacement (backward) was very conspicuous ; no fragments of 
bone had ever escaped. The movements of all the fingers, except the 
index- and little fingers, were unimpaired." 

Tillaux's patient, whom I saw when he was admitted to the Laribois- 
iere Hospital, was twenty years old ; twelve days before admission he had 
fallen backward from a window, about ten feet, striking upon the back 
of his flexed hand. The hand was flexed on the wrist and could not 
be actively extended. There was a dorsal depression corresponding 
to the line of junction of the carpal and metacarpal bones, sharply 
limited above by a transverse prominence which was evidently formed 
by the second row of the carpus, and on the palmar surface at the 
same level the ball of the hand was more prominent than usual. The 
relations of the first metacarpal with the trapezium were unchanged. 
Moderate traction with direct pressure forward reduced the displace- 
ment with a click, and by making pressure in the opposite direction it 
was again produced. After a second reduction the limb was immobil- 
ized for a fortnight. Complete recovery. 

My patient was a lad fifteen years old who was admitted to the Pres- 
byterian Hospital in January, 1887, after having fallen down an eleva- 
tor shaft, a distance of about forty feet, and received, with other injuries, 
a dislocation of the left carpo-metacarpal joints. When I first saw the 
patient, three weeks later, the last-named injury had not been recog- 
nized. The hand was then in almost complete extension on the wrist 
and occupying a plane somewhat anterior to that of the wrist and fore- 
arm. The back of the wrist formed a rounded resistant prominence, 
continuous above with the back of the radius and ulna and terminating 
below in a sharp, well-defined, transverse ridge, which extended com- 
pletely across from the fifth to the second metacarpal and curved up- 
ward on the outer side toward the styloid process of the radius. The 

1 Vigouroux: Bull, de la Societe Anatomique, 1856, p. 15. 

2 Hamilton : Loc. cit., p. 724. 

3 Tillaux: Bull, de la Societe de Chirurgie, 1875, p. 415. 



CARPO-METACARPAL DISLOCATIONS. 725 

finger, passed upward along the back of the metacarpus, was arrested 
by this ridge, which appeared to be about one-quarter of an inch high 
and corresponded to the line of the carpo-metacarpal joints. The first 
row of carpal bones was in normal relations with the forearm and with 
most of the second row, but the relations of the trapezium could not be 
clearly made out. I was under the impression that it was displaced 
somewhat forward from the scaphoid ; it had preserved its relations 
with the first metacarpal bone. The ball of the hand was abnormally 
prominent, and the antero-posterior diameter of the wrist appeared 
thereby increased ; the transverse diameter was unchanged. 

The deformity was easily reduced by traction and direct pressure, 
but immediately recurred when the pressure was removed. Reduction 
was maintained for ten days by keeping the limb in a plaster-of-Paris 
dressing; on removal of the dressing the deformity did not recur, but 
a few hours later the patient reproduced it while experimenting to 
ascertain if the reduction was permanent. It was again reduced, and 
the limb dressed as before. Three weeks later the reduction was com- 
plete and permanent except for some projection forward of the first 
metacarpal and trapezium, and the wrist and the fingers had regained 
their mobility. 

Dislocation of All Five Metacarpals. Poulet x reported a case of incom- 
plete dislocation forward of all five metacarpal bones; the injury was 
caused by a fall from a horse and was associated with a wound of the 
skin on the ball of the hand and slight chipping of the anterior edges 
of the carpal bones. The swelling and the inflammatory reaction were 
so great that an examination was not made until after the lapse of a 
month. There was then found on the back of the hand a projection 
formed mainly by the os magnum, and below it a depression extending 
from the trapezium to the unciform. On the palmar surface the ball 
of the hand projected forward, the palmar fold was effaced, and a deep, 
ill-defined bony prominence could be felt. The interdigital spaces were 
two centimetres nearer the styloid processes than on the other hand. 
Partial reduction and restoration of mobility were obtained. 

Erichsen gives a woodcut and description of a plaster cast in the 
University College Museum, London, taken from a patient in whom 
he thinks this dislocation must have existed ; and Rivington 2 reported 
the case of a patient who had been run over by a wagon and had sus- 
tained a compound dislocation forward of all the metacarpal bones, 
the base of the third projecting through a transverse wound near the 
centre of the palm ; the first phalanx of the thumb was also dislocated, 
and the index-finger so injured that its amputation was necessary. 
The base of the third metacarpal was excised and the dislocation 
centre of the palm ; this was excised and the dislocation reduced. After 
dangerous suppuration and high fever the patient recovered with a 
fairly useful hand. 

1 Poulet : Bull, de la Soc. de Chir., 1884, p. 902. 

2 Eivington : Lancet, 1873, vol. i. p. 270. 



CHAPTER XLIX. 

DISLOCATIONS OF THE THUMB AND FINGERS. 

Proximal Phalanx of Thumb — of the Fingers — Middle Phalanges — Distal 

Phalanges. 

The tables in Chapter XXVII. show that metacarpo- phalangeal 
dislocations of the thumb and fingers and dislocations of the phalanges 
in combined hospital and polyclinic services amount to nearly 25 per 
cent, of all dislocations. Of the metacarpophalangeal dislocations 
those of the thumb are much the most numerous. 

DISLOCATIONS OF THE PROXIMAL PHALANX OF THE THUMB. 

These dislocations are not only the most frequent of those involving 
the phalanges, but they also derive a special interest from the fre- 
quency with which the reduction has been found to be very difficult 
or has entirely failed. The cause of this difficulty has been the sub- 
ject of much study and experiment upon the cadaver during the last 
hundred years, which may be said to have culminated in an elabo- 
rate paper read by Farabeuf l before the Soci^te" de Chirurgie of Paris 
in 1875, in which the anatomy of the joint was described with much 
detail. This description and his explanation of the cause of the diffi- 
culty have been generally copied and accepted by writers in Germany 
and France. The experience I have gained in arthrotomies indicates 
that he somewhat overestimated the importance of the sesamoid bones 
in opposing reduction. 

Anatomy. The head of the metacarpal bone projects on its palmar 
aspect in the form of a well-rounded tubercle or condyle covered with 
cartilage, and more prominent on its outer than on its inner side. 
The ligaments of the joint here concerned are the two lateral and the 
strong anterior or glenoid ; the latter is continuous on either side with 
the others and is stiffened by the development within it of the two sesa- 
moid bones belonging to the short muscles attached to the base of the 
phalanx. The tendon of the flexor longus pollicis lies nearer the inner 
than the outer side ; it is lodged at its lower end in a firm sheath, which 
extends upward to, and is connected with, the glenoid ligament. 

The short muscles and their attachments are made tense by abduct- 
ing the thumb, and are relaxed by pressing the metacarpal bone into 
the palm of the hand. The long flexor and the extensors are relaxed 
by inclination of the hand toward the radial side. Consequently, to 
relax as much as possible the various muscles attached to the thumb, 
the hand should be held in straight extension and slight abduction, 
and the thumb should be pressed into the palm, adduction. 

1 Farabeuf: Bull, de la Societe de Chirurgie, 1876, p. 21. 
726 



DISLOCATIONS OF THE THUMB AND FINGERS, 



27 



The dislocation may be backward, forward, or to the inner side ; 
complete or incomplete. 



Backward Dislocations. 

This is the most frequent form, and the one in which reduction of 
the dislocation is often difficult. 

The common cause is exaggerated dorsal flexion of the first phalanx. 
When the normal limit of the movement is reached the anterior liga- 
ment is put upon the stretch and, the movement being continued, yields 
at its attachment to the metacarpal bone, so that the anterior ligament 
accompanies the phalanx in its movement. 



Fig. 328. 



Fig. 329. 




Incomplete dislocation of the thumb. 



Incomplete dislocation. (Farabeuf.) 



a. Incomplete Form. If this movement is not carried further than 
to the position shown in Fig. 328 the articular end of the phalanx rests 
against the posterior margin of the head of the metacarpal bone, and 
is maintained in this position by the tension of the portions of the 
adductor and abductor muscles which are attached directly to the 
phalanx, for their line of traction is now posterior to and above the 
new centre of motion. The attitude of the member is represented in 
Fig. 329. 

This incomplete form is the one which many people, especially the 
young, can voluntarily produce by contracting the extensor muscles. 
The anterior ligament and the sesamoid bones rest like an apron 
against the anteroinferior articular surface of the metacarpal bone, 
and the dislocation can be readily reduced by moderate traction upon 
the phalanx and flexion. 

6. Complete Form. If, however, the movement is carried further, 
the phalanx entirely leaves the articular surface of the metacarpal 
bone, and moves upward on its dorsum, being followed by the anterior 
ligament and the sesamoid bones (Figs. 330 and 331). The external lat- 
eral ligament is torn, and usually the internal one also ; the tendon of the 
flexor longus pollicis may remain in position, and be tightly stretched 
across the articular face of the metacarpal bone, as has been seen in 
some compound dislocations (e. (/., Esmarch *), or, and much more com- 
monly, it accompanies the inner sesamoid bone to the inner side ot' the 

1 Esmarch : Berlin, klin. Wochenschrift, lS7t>, p. 6-29, tirst case. 



728 



DISLOCATIONS. 



metacarpal ; occasionally it passes to the outer side of the metacarpal 
bone, accompanying the external sesamoid, but probably it does so only 
when, in the production of the dislocation, the thumb is bent to the 
outer side as well as backward. The head of the metacarpal bone 



Fig. 330. 




Simple complete dislocation ; outer side. (Farabeuf.) 

projects through the rent in the capsule, and the tendons of the adduc- 
tor, abductor, and the two portions of the flexor brevis rest against its 
sides. The phalanx stands erect upon the dorsum of the metacarpal 
bone, being held there by the tension of the abductor and adductor. 



Fig. 331. 



Fig. 332. 




Simple complete dislocation ; right 
thumb. The long flexor tendon is dis- 
placed to the inner side. (Farabeuf.) 




Simple complete dislocation. (Farabeuf.) 



The dislocation is sometimes made compound by the rupture of the 
soft parts on the palmar aspect of the joint. 

The appearance of the member is characteristic (Fig. 332 and Plate 
LIL). The phalanx is thrown back vertically upon the metacarpal 
bone, and the latter is adducted, the thenar eminence being consequently 



PLATE LXri 




Fresh Dorsal Dislocation of the Thumb. 



DISLOCATIONS OF THE THUMB AND FINGERS. 729 

increased in thickness and diminished in breadth. The head of the meta- 
carpal bone projects in front as a round, smooth prominence close under 
the skin, over which the tendon of the long flexor may perhaps be felt. 
The phalanx is quite movable from side to side, and can be rotated ; it 
can also be turned down so as to be parallel with the metacarpal bone, but 
this movement should be avoided lest it produce the condition to which 
Farabeuf gave the name of complex fo7-m, the essential feature of which 
he thought to be the interposition of the sesamoid bones between the 
phalanx and metacarpal, and which presents great difficulty of reduc- 
tion. The cause of this difficulty, in all the cases in which I have 
exposed the joint, has been the torn edge of the anterior ligament 
closely drawn across the back of the metacarpal behind its head, and 
a slight nicking of that edge made reduction easy. It is believed that 
flexion of the dislocated phalanx tends to produce this engagement of 
the capsule, but I know that it can take place without that aid. 

Fia. 333. 




Complex dislocation of the thumb ; outer side. The hook raises the periosteal continuation of 
the lateral ligament, exposing the reflected and interposed capsule. (Farabeuf.) 

Treatment. The attitude of the thumb is maintained by the tension 
of the short muscles attached to it, and all that is necessary to over- 
come that opposition is to relax the muscles by pressing the metacar- 
pal bone toward the palm ; then reduction is made, while maintaining 
the phalanx in rectangular dorsal flexion, by pressing its base down- 
ward toward the end of the metacarpal and flexing when the proper 
level is reached. If the torn anterior ligament has not caught behind 
the head, as just described, it will be pushed before the base of the 
phalanx and the latter will turn past the head of the metacarpal in 
flexion as soon as it descends far enough. 

If, on the other hand, the ligament has caught above the head it 
becomes a serious obstacle ; it may sometimes be freed by rotating the 
phalanx while pressing it downward as just described, and the bone 
has sometimes been got into place by forcible traction in straight 
extension. The latter is probably only accomplished after the trac- 
tion has torn the attachments sufficiently to permit the phalanx to be 
drawn quite away from the metacarpal, and I think the plan is dis- 
tinctly inferior to an open arthrotomy. 

In reduction by arthrotomy the incision is made longitudinally 
along the projection of the head of the metacarpal ; as soon as this is 
exposed the sides of the incision are drawn apart and the torn edge of 



730 



DISLOCATIONS. 



the ligament, which can be distinctly seen above it somewhat as in 
Fig. 334, is nicked at its centre ; the dislocation is then easily reduced. 1 
I presume the nicking might be done without a long incision, by pass- 
ing in a tenotome. In some cases it has been sufficient to lift the long 
flexor tendon around to the front from the side of the head, which, I 
presume, is efficient because the tendon is attached to the capsule and 
brings it with it in the movement. 

The prognosis in the past has not been favorable. Polaillon, 2 ana- 
lyzing 58 cases, found that reduction had failed in 11 and had been 
effected only after numerous and prolonged attempts in 16 ; in 8 the 
dislocation was compound, and in 3 of these the head of the metacar- 

Fig. 334. 




Complex dislocation. (Farabeuf.) 

pal bone was excised. In one case (Bromfield), nearly a hundred 
years ago, such violent traction was made that the terminal phalanx 
was torn off; the case has been persistently quoted as a warning ever 
since, but if it is remembered that traction is especially ill-adapted to 
effect reduction in difficult cases the Avarning will not be longer needed. 
In other cases the thumb has become gangrenous in consequence of 
the violence inflicted upon it by the traction. 

In the cases in which the dislocation has been left unreduced and 
the phalanx has been lowered to a position in which it is parallel with 
the metacarpal bone, the usefulness of the member has been in great 
part restored, although, of course, the deformity persisted and the joint 
was immovable. 

Forward Dislocations. 

These dislocations, much rarer than the preceding and less difficult 
to reduce, result usually from a fall or blow upon the back of the 
flexed phalanx — that is, by exaggerated palmar flexion, but in at least 
one case (Lombard) from exaggerated dorsal flexion presumably com- 
bined with direct impulsion of the phalanx toward the palm ; accord- 
ing to Foucart's 3 experiments dorsal flexion needed to be combined 
with forced abduction in order to rupture the internal lateral ligament. 

1 Stimson : New York Medical Journal, March, 30, 1889. 

2 Polaillon : Diet. Encyclopedique des Sc. Med., art. Doigt. 

3 Foucart: These de Paris, 1876, No. 199, quoted by Poinsot. 



DISLOCATIONS OF THE THUMB AND FINGERS. 731 

Pathology. The pathology has been shown by six autopsies, Wood, 1 
Mesehede, 2 Foucart, two cases, Eve/'' and one of my own not before 
reported. In two of these (Foucart, Eve) the injury was recent; in 
Meschede's it had lasted forty-eight days; and in Foucart's second 
case, in Eve's, and in mine it was of long standing. The recent cases 
show, as is also found in experiments upon the cadaver, that the pos- 
terior and lateral parts of the capsule are torn, including the lateral 
ligaments, but that the connection between one or both sesamoid bones 
and the metacarpal bone may persist. The extensor tendons may be 
stretched directly over the projecting head of the metacarpal bone or 
they may be deviated to either side ; in my case the tendon of the 
extensor primi internodii appeared to have been detached and retracted. 
The base of the phalanx lies against the anterior surface of the meta- 
carpal bone, and, in recent cases at least, does not appear to be notably 
displaced upward ; it may lie directly in front, or be somewhat dis- 
placed to either side, and the phalanx may be in straight extension or 
partly flexed. 

In the older cases a more or less complete nearthrosis forms between 
the bones, and fibrous bands and bony outgrowths give the joint suffi- 
cient solidity to make it useful. 

Symptoms. The deformity is characterized by the position of the 
phalanx in front of the metacarpal bone, the projection of the head of 
the latter on the dorsum of the member, and the rather deeply placed 
prominence formed by the base of the phalanx at the lower part of the 
thenar eminence. The thumb appears in some cases to have undergone 
slight rotation about its long axis, and the attempt has been made to 
show a connection between the direction of this rotation and that of 
the lateral displacement of the extensor tendons ; that is, it has been 
claimed that when the rotation is such that the nail looks outward the 
tendons have been displaced toward the outer side, and vice versa. 

In one reported case the dislocation was made compound by rupture 
of the soft parts covering the back of the joint ; recovery was delayed 
by a phlegmon of the ball of the thumb. 

Treatment. Reduction is generally easy, and is effected either by 
traction and coaptation, or, better, by forced flexion of the thumb 
aided, if necessary, by impulsion downward of its base. This latter 
method is analogous to that recommended in the treatment of the 
dorsal variety, but there is not the same urgent reason for it that arises 
in the latter from the relations of the capsule. If any difficulty should 
arise from the tension of the displaced extensor tendons the phalanx- 
should be inclined toward the side on which they lie before making 
the usual manoeuvre. 

Lateral Dislocations. 

Bessel-Hagen 4 reports a unique case of dislocation to the ulnar side. 
The patient was twenty-eight years old ; the injury was caused appar- 

1 Wood : Transactions Pathological Society of London, 1853, vol. iv. p. 250. 

2 Mesehede" : Virchow's Archiv, 1866, vol. xxxvii. p. 510. 

3 Eve : Lancet, 1880, vol. i. p. 133. 

4 Bessel-Hagen : Arch, fur klin. Chir., 1888, p. 386. 



782 DISLOCATIONS. 

ently by forcible bending of the thumb toward the opposite side. 
Reduction by traction and pressure. 

METACARPOPHALANGEAL DISLOCATIONS OF THE FINGERS. 

The shallow cavity formed by the articular surface of the base of the 
proximal phalanx is deepened by the thick anterior portion of the cap- 
sule, which forms, as in the thumb, a stout transverse band or apron 
which accompanies the phalanx in its displacement, and may in like 
manner become interposed between the bones in a backward disloca- 
tion. The resemblance is still further increased by the occasional devel- 
opment of a sesamoid bone in this ligament, especially at the index- 
finger ; its next most frequent appearance is at the little finger. 

Dislocations of the proximal phalanges of the fingers are much less 
frequent, even when taken together, than those of the thumb ; and 
those of the index-finger are more frequent than those of the other 
three fingers. Of 28 cases collected by Polaillon, the dislocation in 
17 was backward, in 10 forward, in 1 not given ; 15 were of the index- 
finger, 4 of the middle, and 3 each of the ring and little fingers ; in 
2 adjoining fingers were dislocated, and in 1 all four. 

Backward Dislocations. 

The common cause is hyperextension (dorsal flexion) of the finger. 
Experiment upon the cadaver and direct observation in compound dis- 
locations or after arthrotomy in irreducible ones, show that the rupture 
of the capsule takes place in front along its attachment to the meta- 
carpal bone. In a case reported by Willemer l the dislocation was 
irreducible by manipulation, and Konig resorted to arthrotomy, 
making an incision on the ulnar side of the palmar surface of the joint 
(index-finger) ; he found the anterior portion of the capsule had been 
drawn back past the articular surface of the phalanx so that it was 
completely interposed between the two bones, and that a sesamoid bone 
was developed on it. This makes the case strictly analogous to the 
complete form of backward dislocation of the thumb, and corroborates 
the opinion that the cause of the irreducibility in the latter is to be 
found in the position of the torn anterior ligament rather than in the 
tension of the tendons of the short muscles. 

Lange 2 says of his case : " The smallest possible cord of the capsule, 
which was torn from its attachment to the metacarpus, had interposed 
itself like an apron between the dorsum of the metacarpus and the 
border of the articular plane of the phalanx. . . . He was obliged 
to incise and draw outward the light lateral parts of the capsule, 
when reduction was effected without difficulty. A fair result was 
obtained." 

A similar condition was observed in a case upon which Volkmann 3 
operated in like manner with a good result, and in one of my own. 

1 Willemer: Centralblatt fur Chirurgie, 1883, p. 566. 

2 Lange: New York Medical Record. 1879, p. 100. 

3 Volkmann : Eeported by Eanke, Berlin, klin. Wochenschrift, 1877, p. 524. 



DISLOCATIONS OF THE THUMB AND FINGERS. 733 

The symptoms are the prominence of the base of the phalanx on the 
dorsum of the hand, and that of the head of the metacarpal bone in 
the palm, more or less shortening of the finger, and loss or diminution 
of function. The finger may be extended or slightly flexed upon the 
metacarpus ; in one case the first phalanx was in rectangular dorsal 
flexion. The middle and distal phalanges are straight or slightly 
flexed. 

In 5 of Polaillon's 17 cases the dislocation was complicated by a 
wound on the palmar aspect of the joint through which the head of 
the metacarpal bone projected, and in another the skin was so tightly 
stretched over the end of the bone that it threatened to slough. In 2 
cases reduction failed (without operation), and in 5 it was difficult, and 
was at last effected by rectangular dorsal flexion of the phalanx and 
direct impulsion downward as in backward dislocation of the thumb. 

Treatment. If the dislocation is incomplete reduction may be easily 
effected by moderate traction followed by flexion, but in the complete 
cases it is certainly more prudent to act as in the similar dislocations 
of the thumb in order more surely to avoid the interposition of the 
anterior portion of the capsule. 

Forward Dislocations. 

The cause, except in an incomplete case observed by Malgaigne, 
has always been notable violence received upon the finger, usually in a 
fall, but the mode of production is not clear. Malgaigne's patient was 
a shoemaker and caused the dislocation by turning in his hand the 
shoe upon which he was at work. 

The symptoms are the presence of the base of the phalanx in the 
palm and the projection of the head of the metacarpal bone at the 
back of the hand. The finger is extended or slightly flexed, and 
appears usually to be deviated to one or the other side, sometimes very 
markedly, with displacement of the extensor tendons toward the same 
side. Reduction has been effected by traction and coaptative pressure. 
Possibly flexion would be efficient in the more difficult cases, as in the 
similar dislocations of the thumb. 

DISLOCATIONS OF THE MIDDLE PHALANGES. 

These dislocations may be backward, forward, or lateral. 

Backward. 

The usual cause is a fall upon the palmar surface of the extended 
finger, which produces the dislocation by hyperextension of the phalanx 
and sometimes ruptures the skin over the front of the joint. The 
phalanx may remain hyperextended upon the proximal one, even to a 
right angle, or may be lowered so that its axis is parallel to that of the 
other. The diagnosis is readily made by examination of the relations 
of the bones, and ordinarily reduction is easily made by direct impul- 
sion of the hyperextended phalanx or by traction and flexion. The 



734 DISLOCATIONS. 

anterior portion of the capsule resembles that of the metacarpopha- 
langeal joints in being thick and rigid, and it is quite possible, there- 
fore, that it may become interposed as above described and make 
reduction difficult or impossible, as in a case treated by Polaillon 1 in 
which all measures failed. It seems advisable, therefore, that the first 
trial should be of direct impulsion upon the hyperextended phalanx, 
and, this failing, the phalanx, still extended, should be pressed bodily 
toward the side on which the flexor tendons may be displaced and then 
rotated so as to carry the tendons forward past the head of the other 
phalanx. 

Forward. 

These may be complete or incomplete, according to the extent to 
w r hich the base of the middle phalanx is displaced upward along the 
palmar aspect of the proximal one. The symptoms are the well- 
marked prominence of the head of the first phalanx on the back, and 
the less marked projection of the base of the second phalanx on the 
palmar surface when it is extended. With the displacement upw T ard 
may be associated some lateral displacement or a lateral deviation of 
the axis of the second phalanx. 

Reduction is easily made by traction and coaptative pressure, but in 
an old case treated by Hamilton the effort had failed, and in one treated 
by Thorens the aid of anaesthesia was necessary. 

Lateral. 

Of these but few cases have been reported ; Polaillon could collect 
only eight, of which the dislocation was to the inner side in seven, and 
to the outer side in one. In a case quoted by him from Chedan the 
middle phalanges of the last three fingers were simultaneously dislo- 
cated toward the inner side, forming almost a right angle with the side 
of the first phalanx. Duplay, 2 who saw a case, says " the dislocated 
phalanx is markedly deviated inward so as to form almost a right angle 
and to cross the course of the adjoining finger. At the apex of the 
angle the lower end of the first phalanx can be felt ; the dislocated 
phalanx projects on its inner side." 

In Rollet's case of dislocation to the outer side the base of the second 
phalanx of the ring finger projected upon the outer side of the first 
phalanx ; the second phalanx was somewhat inclined inward, and the 
distal phalanx was slightly flexed. The shortening was about two- 
thirds of a centimetre. 

In two of the eight cases the dislocation was compound, but the 
patients recovered without anchylosis. 

Reduction was easily effected in every case by traction and coaptation. 

DISLOCATIONS OF THE DISTAL PHALANGES. 

These dislocations may be backward, forward, or lateral, the former 
being by far the most frequent ; forward dislocations have, I believe, 
been encountered only in the thumb. 

1 Polaillon : Loc. cit., p. 184. 2 Duplay : Pathologie Externe, vol. iii. p. 332. 



DISLOCATIONS OF THE THUMB AND FINGERS. ?35 

Backward. 

Backward dislocation of the distal phalanx is commonly caused by 
a fall or blow upon the end of the outstretched finger. The disloca- 
tion may be complete or incomplete, simple or compound, and it may 
be directly backward or backward and to one side. 

The anterior ligament is torn away from one or the other bone, in 
the thumb usually from the proximal phalanx, in the fingers from the 
distal one. The lateral ligaments remain intact, unless the dislocation 
is to one side as well as backward. The flexor tendon may be torn 
away from its attachment, or it may be displaced to one side. 

Reduction is usually easy, but may be made difficult by interposition 
of the anterior portion of the capsule when this accompanies the distal 
phalanx or by the tension of the displaced tendon. In several com- 
pound cases of the thumb the obstacle created by the tendon was clearly 
demonstrated and was overcome by drawing the tendon aside with a 
blunt hook or dividing it. 

The phalanx may be hyperextended, or straight, or flexed across the 
end of the proximal one. The coexistence of a wound on the palmar 
surface of the joint is frequent, thirty-two times in fifty-five cases col- 
lected by Polaillon, and has led to very serious consequences, anchy- 
losis, gangrene, suppuration extending to the forearm, tetanus. 

Although ordinarily of easy reduction, yet in one-quarter of Polail- 
lon's cases reduction failed. As his list is made up largely of reported 
cases it undoubtedly contains an exceptionally large proportion of diffi- 
cult and complicated ones, but still the number of failures, thirteen, is 
large enough to indicate that reduction may often require much care 
and skill. The principles controlling it are the same as in the back- 
ward dislocations of the other joints, and although simple traction 
has often sufficed it is prudent to refrain from it and to reduce by 
direct impulsion of the hyperextended phalanx, especially at the 
thumb. In one case Hamilton divided the lateral ligaments subcuta- 
neously. 

Forward. 

These dislocations have been observed only at the thumb, and in a 
large proportion of the reported cases they have been made compound 
by a wound on the palmar surface. The cause, in the few reported 
cases, has been a blow upon the end of the phalanx by which it was 
forcibly hyperextended. In some cases the phalanx remained in this 
position, its dorsal surface resting against the articular face of the 
proximal phalanx, and its base projecting on the palmar surface; in 
other cases the phalanx was slightly flexed, and its base displaced 
upward along the anterior surface of the proximal one. 

Reduction has usually been easy by traction or direct pressure. 

Lateral. 

These dislocations, of which only four or five have been reported, 
have been caused by falls, by a kick, and by violently shaking the 



73(5 DISLOCATIONS. 

hand while grasping it by the end of the finger. The phalanx may 
preserve its parallelism with the other, being simply displaced upward 
along its side, or it may form a lateral angle with it, its base resting 
against the side of the other. In Gogue's case, quoted by Malgaigne, 
there was a transverse wound fifteen millimetres long through which 
the head of the middle phalanx protruded. In Duges's case reduction 
was not attempted ; in the others it was easy. 



CHAPTER L. 

DISLOCATIONS OF THE PELVIS. DISLOCATIONS OF THE 

COCCYX. 

The union of the two innominate bones at the symphysis pubis is 
by a solid fibro-cartilaginous band, and without an articular cavity, 
and the rupture of this band, or its separation from one or the other 
bone, belongs more properly among fractures than among dislocations. 
Between the articular surfaces of the ilium and sacrum there is usually 
an articular cavity, but it is often more or less obliterated by fibrous 
union between the opposed cartilaginous surfaces. Pure separations 
at these points without fracture are rare, and, except at the pubic sym- 
physis, hardly to be diagnosticated with certainty during life. The 
reader is, therefore, referred for most that pertains to the subject to the 
chapter upon fractures of the pelvis. 

Malgaigne described the lesions as dislocations, and most writers have 
followed his example. His classification is as follows : 

Dislocations of the pubic symphysis. 

Dislocations of the sacro-iliac symphysis. 

Dislocations of these two symphyses, or of the ilium. 

Dislocations of the two sacro-iliac symphyses, or of the sacrum. 

Dislocations of the three symphyses, or of the three bones simulta- 
neously. 

Dislocations of the coccyx. 

Of these, only the last is, strictly speaking, to be deemed a disloca- 
tion. 

DISLOCATIONS OF THE COCCYX. 

The systematic descriptions of dislocations of the coccyx which are 
given by the earlier writers were called in question by those of the first 
half of the present century, some of whom, especially Boyer, went so 
far as to deny that the lesion had ever occurred. Malgaigne, however, 
collected six cases of dislocation forward, and described a backward 
form on the authority of Lauverjat. To these six may be added four 
that have been since reported, Roeser, 1 Bonnefont, 2 two cases, and 
Mouret, 3 the first of which is an example of a variety, lateral disloca- 
tion, that has not heretofore been described. It must further be said 
that many cases have been encountered and reported in which a group 
of symptoms identical with those observed in cases reported as dislo- 
cations, and following similar accidents, falls, blows upon the anal 
region, has been presented, and the conclusion seems to be unavoid- 
able, either that dislocations or fractures of the coccyx are much more 

1 Roeser: Froriep's Notizen, 1857, vol. ii. No. 10. Abstract in Brit, and For. Mod. Chir. 
Rev., 1857, vol. xx. p. 414. 

2 Bonnefont: Union Medieale, 1859, vol. i. p. 136. 

3 Mouret: Rec. de Mem. de Med. Chir. et Pharm. militaires. 1859, vol. i. p. 350. 

47 737 



738 DISLOCATIONS. 

frequent than the number of reported cases indicates, or that the prom- 
inent symptoms which accompany the recognized cases, the excessive 
pain, disability, and general nervous disturbance, are due to something 
else than the displacement of the bone. Against the latter alternative 
may be urged the immediate relief and prompt recovery which have 
followed the reduction of the displacement. Six cases in which the 
general symptoms were similar to those of dislocation, but in which no 
displacement was recognizable, are reported by Warren, 1 and Moure t ? s 
case may perhaps be classed with them. 

Of eight of the above cases in which the sex is noted, six were 
women, and two men ; all were adults ; and the obscure injury just 
referred to, in which the symptoms are the same, except that no dis- 
placement is recognizable, is also much more frequent in women than 
in men. 

Dislocations Forward. 

The usual cause is violence received upon the region of the coccyx 
in a fall upon the buttocks or astride a bar, or by the breaking of a 
chamber upon which the patient was sitting. The two men, Ravaton, 
Mouret, were injured while on horseback, one of them suddenly in 
jumping a ditch, the other without special cause or incident, the pain 
coming on gradually, and increasing for twenty-four hours, and then 
suddenly becoming very severe after a slight change of position, with 
a sensation of something slipping in the rectum. 

The pain at the moment of the accident is so severe as sometimes to 
cause the patient to faint ; there is pain in defecation, and frequent calls 
to urinate. The pain radiates down the thighs, and sometimes over 
the trunk, head, and arms ; the patient is unable to sit up, and the 
slightest movement may greatly increase the suffering. Coughing and 
sneezing and sometimes even every act of inspiration increase the local 
pain. If the condition remains unrelieved (Turner, a week ; Ravaton, 
seventeen days ; Bonnefont, a month) the general health suffers seri- 
ously, the patient becomes feverish, and the mind dulled. 

External examination may show an ecchymosis and swelling over the 
situation of the coccyx and a displacement of this bone forward ; the 
finger introduced into the rectum recognizes an angular displacement of 
the coccyx, in which its point is directed forward, and which is some- 
times so great that the bone stands almost at right angles to its normal 
position, and presses the posterior wall of the rectum sharply forward. 

If now the finger is hooked over the projecting end of the coccyx 
it can be readily drawn back into place, and the reduction is followed 
by immediate, instantaneous relief of all the symptoms. A marked 
tendency to recurrence usually exists and may make it necessary to 
repeat the reduction several times. In one of Bonnefont's cases a gum 
catheter with a stylet was bent into the shape of a hook and so placed in 
the anus that by traction upon the projecting portion the bone could be 
kept in place. In Turner's case the cure was less complete ; the coccyx 
preserved an abnormal mobility for many years, and the patient was 
obliged to facilitate defecation by introducing her finger into the anus. 

1 Warren : Surgical Observations, Boston, 1867, p. 596. 



DISLOCATIONS OF THE COCCYX. 739 

Dislocation Backward. 

Dislocation backward is lightly mentioned by some writers as a not 
infrequent accident during parturition. Malgaigne quoted Lauverjat 
as follows : " The considerable deviation backward of this bone some- 
times causes its dislocation. I have seen one case. The patient suf- 
fered astonishingly, and could not sit ; I reduced the coccyx and she 
was immediately cured." 

Lateral Dislocation. 

Of this only one case, Koeser, has been reported. The patient a 
large, corpulent woman, thirty-six years old, fell astride the back of a 
chair. She at once suffered severe pain in the coccygeal region, much 
aggravated by attempts to sit, but she was able to go about for some 
hours. At last the pain became so severe that she took to her bed, 
when she found she could neither move nor turn. When seen the next 
day there was so much immobility and stiffness of the body as to sug- 
gest tetanus. Besides the severe pain in the coccygeal region she com- 
plained of a painful, tense, dragging sensation, extending up toward 
the nape, and along the arms to the fingers, which felt numb. She 
could not bear to make the slightest movement. The head was con- 
fused, and the intellect somewhat clouded. No unnatural sensation in 
the lower limbs ; urine and feces were passed naturally. 

A small swelling was felt on the left side of the fissure of the but- 
tocks, which proved to be the coccyx torn away from the sacrum, and 
carried toward the left ischium. The end of the sacrum from which 
it had been displaced could be plainly felt. The finger in the rectum 
showed the exact nature of the displacement still better, and when firm 
pressure was made downward and to the right against the displaced 
bone, it suddenly resumed its normal position. The patient declared 
she immediately felt quite another being, the confusion of the head and 
painful sensation along the spine and arms disappearing. At the end 
of the fifth day no inconvenience beyond a slight burning pain near 
the sacrum remained. 

The severity of the symptoms in all these forms appears to be due 
to a special sensitiveness of the region which, as has been said, is mani- 
fested by similar symptoms associated with no traumatism or local 
change, or, as in a case of my own, only with a dry arthritis of the 
joint. The removal of the coccyx in the non-traumatic cases (coccy- 
godynia) gives great relief. 



CHAPTER LI. 

DISLOCATIONS OF THE HIP. 

Anatomy — Statistics — Cases of Compound Dislocations — Classification— Back- 
ward Dislocations : Dorsal, everted dorsal, anterior oblique. 

Anatomy. 

The bony constituents of the hip-joint are the acetabulum, or cot- 
yloid cavity of the os innominatum, and the globular head of the femur. 
The former is an almost hemispherical cavity, situated at the junction 
of the ilium, ischium, and pubis, and formed by the projection from 
their outer surface of a strong bony rim, which is especially thick and 
prominent behind and above, and is lacking below for nearly an inch 
at the point where the cavity adjoins the foramen ovale, the cotyloid 
notch. The depth of the cavity is increased by a iibro-cartilaginous 
rim set upon its edge, the labrum cartilagineum, or cotyloid ligament, 
which crosses the cotyloid notch, and is there termed the transverse 
ligament. The wall of the cavity is thin at its centre and lower part, 
and is elsewhere very thick and strong. Its growth takes place at the 
junction of the three bones which combine to form it, this junction 
being marked during the period of growth by a thin layer of conjugal 
cartilage having the shape of an inverted Y. 

The head of the femur is rather more than half of a sphere, having 
a radius of about an inch, and is so placed upon the neck that rather 
more than half of its cartilage-covered surface is in front and above 
(in the upright position) and rather less than half is behind and 
below. At a point a little below that at which a prolongation of the 
long axis of the neck would touch its surface is a depression, within 
which the upper end of the ligamentum teres is attached. 

The neck is directed inward, upward, and slightly backward from 
its junction with the shaft, the angle which it makes with the long 
axis of the latter being about 130 degrees. The great trochanter, con- 
tinuous with the outer surface of the shaft, overlaps the neck above 
and behind, its highest part being situated posteriorly and curved 
inward ; the portion which is most external and most nearly- subcuta- 
neous is about an inch below the upper margin. 

The capsule is attached above along the entire periphery of the 
cotyloid cavity, just outside the free margin of the labrum cartilagi- 
neum, and below to the femur at or near the junction of the neck and 
shaft, extending in front to the inter-trochanteric line, above nearly 
to the root of the great trochanter in the digital fossa, behind to the 
neck itself a little short of its outer limit, and below to the upper part 
of the lesser trochanter. It is composed of fibres arranged longitudi ■ 
740 



DISLOCATIONS OF THE HIP. 



741 



Fig. 335. 



nally and circularly, and varies greatly in strength and thickness at 
different points. Those portions which are especially thickened by 
multiplication of the longitudinal fibres are known as accessory liga- 
ments ; of these the strongest and most important is the one situated 
in the anterior part of the capsule, and known as the ilio-femoral liga- 
ment, or the ligament of Berlin, or Bigelow's Y-ligament (Fig. 385). 
This arises from the anterior 
inferior spine of the ilium, and 
from the surface of the bone 
immediately behind it and above 
the edge of the acetabulum, and 
its fibres passing downward 
diverge to form two strong 
bands, of which the inner passes 
almost vertically to the lower 
part of the anterior intertrochan- 
teric line, and the outer to the 
upper part of the same line. 
The ligament is about one-fourth 
of an inch thick at its thickest 
part, and is very strong, perhaps 
the strongest in the body, and 
will sustain without rupture a 
strain of from 250 to 750 pounds 
(Bigelow). Its inner portion is 
especially concerned in limiting 
extension of the limb; its outer 
portion in limiting eversion. 

The other thickened portions 
of the capsule are those known 
as the pubo-femoral and ischio- 
femoral ligaments ; the former 
arises from the anterior and 
inferior portion of the acetabular 
margin and the pubis as far 
inward as the pectineal eminence, 




The ilio-femoral, or Y-ligament. (Bigelow.) 

and extends in the anterior and 



lower part of the capsule to its insertion above the small trochanter. 
The ischio-femoral ligament is a strong band of fibres on the outer 
and posterior portion of the capsule, arising from the groove on the 
ischium below the acetabulum. The pubo-femoral ligament limits 
abduction; the ischio-femoral limits inversion. On each side of the 
pubo-femoral band the capsule is very thin ; outside and behind the 
Y-ligament the capsule is very strong, limiting adduction and inward 
rotation (Bigelow). 

The joint is thickly covered in by muscles, of which it is desirable 
here to mention only one, the obturator interims, which plays an 
important part in the backward dilocations. This muscle, arising 
from the inner surface of the obturator foramen and the surface of 
bone between it and the great sacro-sciatic notch, passes outward 



742 DISLOCATIONS. 

through the small sacrosciatic notch, turns sharply forward, and is 
inserted upon the front part of the inner surface of the great trochanter 
in conjunction with the two gemelli which arise respectively from the 
spine and tuberosity of the ischium. Above it is the pyriformis, below 
it the quadratus femoris. 

The centre of the head of the femur lies about two inches directly 
below the anterior inferior spine of the ilium, and at about the same 
distance downward and outward from the centre of, and in a direction 
at right angles to, a line drawn from the anterior superior spine of the 
ilium to the spine of the pubis. When the bones are normal and in 
place, and the limb is partly flexed, a line drawn across the outer aspect 
of the thigh from the anterior superior spine of the ilium to the lowest 
part of the tuberosity of the ischium will cross the upper part of the 
great trochanter. This is known as Nelaton's, or the ischio-iliac line ; 
its relations to the trochanter have great diagnostic importance. In 
the child, according to Hueter, the trochanter is brought somewhat 
higher by the relative shortness of the neck of the femur. 

Extension and abduction are checked in the living by the ligaments 
of the joint, flexion and adduction by the muscles or by the contact of 
the limb with the abdomen in flexion. The range of abduction and 
adduction is further modified by the position of the limb as regards its 
flexion and its rotation about the long axis. 

The position of the limb in which dislocation of the hip most 
frequently occurs is that of flexion, adduction, and inward rotation, 
and the dislocation which then occurs is one of the backward forms, 
although after the head of the bone has left the socket abduction and 
outward rotation of the limb may lodge it in the obturator foramen. 
In this position the posterior and inferior portion of the capsule is put 
upon the stretch and ruptured. By outward rotation and abduction the 
head may be forced out at the lower and inner part of the capsule below 
the pubo-femoral ligament, toward the obturator foramen ; in each case 
a new centre is found for the exaggerated movement in the more or 
less direct contact between the neck of the femur and the margin of 
the acetabulum or in the tension of part of the Y-ligament. The force 
which produces the dislocation, therefore, almost always acts indirectly, 
either by moving the limb upon the fixed trunk or by moving the 
trunk upon the fixed limb. In the great majority of cases the 
Y-ligament remains untorn, and by the restraint which it exerts upon 
the movements of the displaced femur it determines in a large measure 
the character of the secondary displacement, the attitude in which the 
limb comes to rest, and the manipulations by which the dislocation can 
be reduced. This influence is so great that Bigelow based upon it the 
distinction which he made between " regular " and " irregular " dis- 
locations, the former including those cases in which the ligament 
remained untorn and the attitude of the limb was in consequence char- 
acteristic ; the latter those in which the ligament was more or less torn 
and the attitude and displacement variable. The distinction has some- 
times an important bearing upon the treatment and deserves to be 
preserved. 



DISLOCATIONS OF THE HIP. 74:3 

Statistics. 

The tables in Chapter XXVII. show that the percentages of dislo- 
cation of the hip, compared with all dislocations, vary from 1.4 to 2 
per cent. Agnew 1 says that of 912 dislocations admitted to the 
Pennsylvania Hospital 89 (9.75 per cent.) were of the hip. Of 
Kronlein's 8 cases 4 were in patients not more than ten years old, and 
of Prahl's 2 41 cases 12 were of the same age, 8 were between eleven 
and twenty, and 11 were between twenty-one and thirty years old. 
This preponderance in youth is, however, not found in Agnew's list or 
in the 41 cases collected by Malgaigne or the 84 cases collected by 
Hamilton. The latter were divided as follows : 

Under 15 years 15 

15 to 30 " 32 

30 " 45 " 29 

45 " 60 " 7 

60 " 85 " . 1 

Agnew's 89 cases are thus divided : 

15 to 25 years .39 

25 " 35 " 26 

35 " 45 " 12 

45 " 55 " 6 

55 " 65 " 5 

65 " 75 " . 1 

Although the numbers are larger in Hamilton's collection than in 
Prahl's, yet, as the latter are the integral statistics of a single hospital 
and dispensary, I think its percentages are more likely to represent the 
actual proportions than those of a collection of published cases are. 
I do not know how to account for the absence from Agnew's list of 
patients under fifteen years of age. 

The earliest age at which a dislocation has been reported is six 
months ; 3 it was a dislocation upon the obturator foramen, and was 
caused by the fall of a chair in which the child was tied. In the 
report by W. A. Johnson, 4 of a clinical lecture by Prof. Gross, it is 
said, " upward of six years ago this child, M. S., aged seven years, had 
a fall," and received a dorsal dislocation of the hip. The note is 
entitled, " Dislocation of the hip-joint in a child six months of age." 
Bartels 5 reported a dorsal dislocation at eleven months caused by the 
effort made to put on a shoe. Several others have been reported 
between the ages of eighteen months and five years. 

The oldest patient is one reported by Kennedy, 6 a woman, aged 
ninety-one years and five months, who received a dorsal dislocation oi' 
the right hip by a fall, while walking across a smooth floor ; it was 
reduced on the twelfth day by manipulation, and two days later the 
patient died. The autopsy verified the diagnosis. The next oldest 

1 As;new: Surgery, vol. ii. p. 89. 

2 Prahl : Inaug. Dis., Centralbl. fiir Chir., 1881, p. 57. 

3 Powdrell: Lancet, 1868, vol. i. p. 617. 

4 Johnson: Philadelphia Medical Times, 1876-7, vol. vii. p. 5. 

5 Bartels: Arch, fur klin. Chir.. 1874, vol. xvi. p. 650. 

6 Kennedy: Cincinnati Lancet and Clinic, 1878, vol. i. p. 256. 



744 DISLOCATIONS. 

patient, eighty-six years, was also a woman, 1 and the next a man 
eighty-one years old, whose dislocation was suprapubic and was veri- 
fied by autopsy four years later ; the neck of the bone was broken by 
an attempt to reduce while the injury was recent ; the case was reported 
by Verneuil. 2 

The injury is much more common in males than in females; of 
Agnew's 89 cases, 11 were women ; of 115 cases collected by Hamilton, 
104 were males. 

Concerning the relative frequency of the different varieties it can be 
said that those in which the head of the femur is found resting upon 
the lower part of the ilium behind the outer posterior half of the ace- 
tabulum, the so-called " iliac " dislocation, to preserve for the moment 
the old classification, or still lower down on the upper part of the 
ischium, " ischiatic " dislocations, are much more frequent than those 
in which it rests in front or on the inner side of the acetabulum, the 
suprapubic and obturator dislocations. The dislocations upon the dor- 
sum of the ilium are generally thought, on clinical evidence, to be 
more frequent than the ischiatic, but a comparison of the cases exam- 
ined after death does not corroborate this view ; Malgaigne collected 
10 autopsies of ischiatic dislocations, and only 6 of the iliac, one of 
these being primarily ischiatic, and Lossen, 3 taking only cases reported 
since 1855, found 19 ischiatic and only 5 iliac. Probably Malgaigne's 
supposition is correct that many ischiatic cases observed clinically are 
thought to be iliac ; indeed, it will further appear that in many " iliac " 
dislocations the head of the femur has primarily passed downward and 
backward, and that its presence upon the dorsum of the ilium is due 
to a secondary displacement upward. Roser goes so far as to claim 
that the iliac dislocations, in which the head of the femur has left the 
cotyloid cavity by its upper posterior portion, are the rarest of all the 
principal forms. Of the two anterior forms the obturator seems to be 
more frequent than the suprapubic, but the reported cases are too few 
to justify a positive assertion. 

Simultaneous dislocation of both hips has been reported in about thirty 
cases (see Chapter LIIL). 

Compound dislocations are very rare, as might be expected from the 
thickness of the soft parts which everywhere cover in the joint. Illus- 
trative cases are those of Walker, 4 Bransby Cooper, 5 Macouchy, 6 
Moxon, 7 a German military surgeon, 8 Taylor, 9 Woodward, 10 Langmaid 
and Cabot, reported by Perkins, 11 and Cheever. 12 In the first case the 
patient fell under a wagon, the wheel passing over the back of his 
pelvis and right thigh ; the head of the femur was forced " forward 

1 Gauthier ■ Quoted bv Malgaigne, loc. cit., p. 805. 

2 Verneuil : Bull, de la Soc. de Chir., 1865, vol. vi. p. 495. 

3 Lossen : Deutsche Chirurgie, Lief. 65, p. 30. 

4 Walker : Quoted by Cooper, loc. cit., p. 80. 

5 Cooper : Loc. cit., p. 76. 

6 Macouchy : Dublin Hospital Gazette, 1872, vol. i. p. 21. 

7 Moxon : Medical Times and Gazette, 1872, vol. i. p. 96. 

8 Centralblatt fur Chirurgie, 1880, p. 504. 

9 Taylor : Lancet, 1881, vol. i. p. 732. 

10 Woodward : Boston Medical and Surgical Journal, 1883, vol. cviii. p. 129. 

11 Perkins : Ibid., October 16, 1890, p. 362. 

12 Cheever : Ibid., May 28, 1891, p. 523. 



DISLOCATIONS OF THE HIP. 745 

upon the groin " and through the skin. Reduction ; suppuration ; 
death in three weeks. The second is not spoken of by Cooper as a 
compound dislocation, but the history indicates that it probably was 
one ; the patient, a lad seventeen years old, was run over by a wagon, 
the wheel passing across the back of his thigh and producing a dislo- 
cation forward and inward, the head of the femur lying to the inner side 
of the great vessels. A rather large lacerated wound was situated just 
below Poupart's ligament, a little to the inner side of its centre. Pro- 
fuse suppuration followed, and the patient died on the twentieth day. 

Macouchy's patient was a boy fourteen years old, who fell from a 
mast to the deck, a distance of sixty feet, and received, in addition to 
the dislocation, a fracture of the base of the skull. When seen, he 
was sitting on the deck with the head of the femur appearing between 
his legs, through his pilot-cloth trousers, as if protruded from his anus. 
The head, neck, and great trochanter protruded through the integu- 
ments covering the posterior third of the ischium, the head of the bone 
resting on the posterior part of the tuberosity of the ischium of the 
opposite side. The head was sawn off, and the shaft replaced. The 
patient died two days later. 

Moxon's patient was injured by a moving train and died shortly after- 
ward in Guy's Hospital. The position of the limb was that of disloca- 
tion on the dorsum ilii. There was a large irregular rent in the skin 
corresponding to the junction of the left sacro-sciatic ligament with the 
tuber ischii. On passing three or four fingers into the hole a way was 
found through a pulp of torn muscles and bloodclot, till the fingers 
rested on the naked head of the thigh bone. The gluteal muscles were 
much torn up and infiltrated with blood. The head of the thigh bone 
lay half an inch outside the great sciatic nerve, free under the remains 
of the glutei. It had escaped through the muscles immediately around 
the joint by passing between the quadratus femoris and obturator 
internus. A portion of the head of the bone remained in the socket, 
attached by the round ligament. 

The fifth case was that of an artilleryman who fell in front of the 
gun ; his left leg was bent back so that the heel lay against the back 
of the shoulder, and the head of the femur projected through the fold 
of the groin. There was profuse bleeding from the femoral vein. 
Death in twenty-four hours. 

Taylor's patient was a lad seventeen years old, who was overthrown 
by a falling tree and received a dislocation into the obturator foramen 
together with an irregular wound nearly two inches long in the 
perineum through which the head of the femur could be distinctly 
felt. Most of the muscles had been separated from the descending 
ramus of the pubis and the ascending ramus of the ischium. Reduc- 
tion was made with some difficulty, and the limb immobilized on a Long 
side splint. The wound healed promptly, and at the end of nine weeks 
the splint was removed, but on the next day inflammatory symptoms ap- 
peared on the side of the hip, and an abscess formed and was opened. 
Eight months later Taylor met the patient riding on horseback. 

Woodward's patient, a boy twelve years old, was caughi under a 
freight car and rolled over and over, receiving several fractures in 



746 DISLOCATIONS. 

addition to the dislocation. The wound was a slit about two inches 
long on the inner side of the thigh two and a half inches below the 
angle of the pubes. The head of the femur, together with the great 
trochanter entirely stripped of its muscles, projected completely through 
the opening for about four inches and lay across the scrotum. Its point 
of exit was just anterior to the adductor longus. No fracture of the 
femur or pelvis was detected, and the great vessels were uninjured. 
The patient died in five hours, and after death reduction could not be 
made. 

Langmaid's patient was a girl eight years old who had been run 
over by a heavy wagon. The wound extended from a point one inch 
above and within the anterior superior spine across the groin to the 
inner side of the thigh, the head of the femur presenting in it near its 
centre. " The muscles directly under the wound were severed, the 
adductor longus completely, the pectineus, psoas, and gracilis partially." 
Considerable hemorrhage ; the femoral vessels were " outside and 
beneath the neck of the femur." Reduction. The wound suppu- 
rated, but the child recovered with complete anchylosis. 

Cheever's patient, a man fifty years old, was thrown down by the 
fall of a heavy case ; the head of the femur protruded through a wound 
in the groin below the outer part of Poupart's ligament. The head 
was excised ; patient died on the third day. The autopsy showed the 
femoral vessels to be intact. Death was apparently due to associated 
injuries, shock, and extensive fat embolism of the lungs. 

The gravity of the condition, 7 deaths in 9 cases, is largely due to 
associated injuries and shock, 5 deaths ; in the remaining 4 the wound 
suppurated after reduction, and 2 of them died. The urgent question 
is whether or not to excise the head of the femur in order to diminish 
the danger if suppuration should follow. In fresh, uninfected cases 
I should think it unnecessary if ample drainage w r as provided. 

Classification. 

The classifications adopted by the earlier writers were necessarily 
faulty and deficient because of the lack of recorded experience and 
post-mortem examinations. That of Hippocrates, containing four 
principal forms, outward, inward, forward, and backward, was em- 
ployed, according to Malgaigne, until the seventeenth or eighteenth 
century, although the terms do not seem always to have been applied 
in the same sense. Petit, in the eighteenth century, made two main 
groups, inward and outward, each with two subdivisions, the four 
being upward and inward, downward and inward, upward and out- 
ward, and downward and outward, but he thought it impossible that 
the latter form could occur. Verduc, about the same time or a little 
earlier, sought to establish a classification based upon the place at which 
the head of the femur came to rest, and in this he was supported by 
Duverney and Bertrandi, and thus arose the terms dislocation upon the 
ilium, upon the ischium, upon the pubes, into the foramen ovale. Sir 
Astley Cooper gave us dislocations upward, or on the dorsum ilii, down- 
ward,, or into the foramen ovale, bachvard, or into the ischiatic notch, and 



DISLOCATIONS OF THE HIP. 747 

dislocation on the pubes ; and Gerdy followed with suprapubic, sub- 
pubic, iliac, sacro-sciatic, and ischiadic, the latter being directly down- 
ward. 

Malgaigne was the first to bring to the subject the results of careful 
study of many pathological specimens ; he showed that in the back- 
ward dislocations the head of the femur did not go so far as the ana- 
tomical terms used in Cooper's classification, for example, would 
indicate, but that, on the contrary, it usually remained so near the 
cotyloid cavity that it partly overlapped it, " incomplete" disloca- 
tions, as he called them, and he proposed a classification in four groups, 
of which the first two were the same as Petit's, though the names are 
different, as follows : 

Dislocations backward \ ?*"? complete incomplete. 

( ischiatic, complete, incomplete. 

Dislocations forward { j^^ 

Dislocations upward supracotyloid. 

t.. , ,. i j f subcotyloid. 

Dislocations downward j subp erineal. 

The names ilio-pubic and ischio-pubic were taken from those of cor- 
responding depressions on the margin of the cotyloid cavity along 
which the head of the femur was thought to pass, and, acting on the 
same plan, Nelaton gave the name ilio-ischiatic to all the backward 
dislocations, which Malgaigne preferred to divide into two groups. 

In Germany Roser and Busch adhered to the method of classifica- 
tion according to the direction taken by the head of the femur ; later, 
Albert made three groups : backward, forivard and upward, and for- 
ward and downward, and Konig and Lossen four : backward (iliac and 
ischiatic), forward {suprapubic and infrapubic), supracotyloid, infra- 
cotyloid. 

In England Sir Astley Cooper's classification has been quite closely ad- 
hered to, although some surgeons (Erichsen) place the backward dislo- 
cations, those " upon the dorsum ilii " and " into the sciatic notch/' 
in one group and call them " dislocations backward and upward." 

In America Hamilton used Cooper's classification; and Agnew did 
the same, although he grouped the iliac and ischiatic together as vari- 
eties of a single form " upward and backward." 

Bigelow, 1 to whose researches and writings so much of the later 
advance in the knowledge of the subject and in the treatment of the 
injury is due, made a classification of seven regular and principal 
forms, which he based not merely upon the direction in which the bone 
had been dislocated or the point at which it came to rest, but also upon 
the integrity of the Y-ligament or the rupture of its outer branch, and 
the changes in the attitude of the limb which arise from such rupture. 
Such a classification was open to the objection that it gave equal rank 
to forms which were only variations of others, and a few years later he 
modified it 2 by grouping all under four heads and by suppressing the 
distinction between the "dorsal" and the "dorsal below the tendon," 

1 Bigelow: The Hip. - Bigelow: Lancet, 1S7S. vol. i. p. 894. 



748 DISLOCATIONS. 

which latter name he had previously given to the lower of the two 
dorsal varieties, the " dislocations into the sciatic notch " of Cooper. 
His new classification, then, was the following : 

External to the socket ; comprising the dorsal and the dorsal with 
e vers ion. 

Internal to the socket ; on the perineum, the thyroid foramen, and 
the pubes. 

Below the socket ; dislocation toward the tuberosity of the ischium. 

Above the socket ; the subspinous, the supraspinous, and the anterior 
oblique. 

This also was open to the serious objection that varieties w T hich were 
alike in their mode of production, in the point at which the head of 
the femur left the socket, in the direction it afterward took, and in 
treatment were placed in different main divisions, and he, therefore, 
went further and presented in the same paper the following classifica- 
tion which he recommended as a sufficient " practical grouping." 

Dorsal, comprising the dislocation on the tuberosity of the ischium, the 
dorsal, the everted dorsal, the anterior oblique, and the supraspinous. 

Thyroid, comprising that in the perineum and that on the thyroid 
foramen. 

Pubic, comprising the pubic and the subspinous. 

Turning now to the results of the examination of specimens and of 
experiments upon the cadaver, it appears that in the more frequent 
forms the head of the femur passes over the outer, posterior, margin 
of the cotyloid cavity, usually at or below its horizontal diameter, 
while the limb is flexed, adducted, and rotated inward ; then by 
the sinking of the knee the femur turns upon its attachment to the 
Y-ligament as a centre, and the head rises to a higher level along the 
outer surface of the acetabulum or further backward on the flat surface 
of the ilium in front of, and seldom higher than the apex of, the great 
sciatic notch. It is to be borne in mind that this apex is not very 
much above the level of the highest part of the cotyloid margin. In 
this movement the head of the femur may pass behind the untorn ten- 
don of the obturator internus, leaving that tendon between itself and 
the acetabulum ; or, if it crosses the margin of the cotyloid cavity at or 
above its horizontal diameter, it may tear the obturator internus and 
pyriformis or pass between these muscles and come to rest at the same 
point as before. The former is the dislocation " below the tendon," 
the latter the " dorsal " or the dislocation " upon the dorsum ilii," as 
these terms were originally used, but the distinction is one which can- 
not often be made clinically. The important difference between them 
is in the situation of the rent in the capsule, which is higher in the 
latter than in the former, and will probably permit reduction by trac- 
tion obliquely downward. 

Exceptionally, if, after the dislocation has occurred, the knee is still 
further lowered and the limb abducted and rotated outward, the outer 
branch of the Y-ligament ruptures and the head of the femur passes 
forward along the ilium toward its anterior inferior spine or the 
interval between the two spines, the " everted dorsal " of Bigelow, 
the " supraspinous " or part of the " supracotyloid " of others. The 



DISLOCATIONS OF THE HIP. 749 

attitude of the limb in this is very different from that of the com- 
mon backward dislocation of which this is a variety by secondary 
displacement. 

But the head of the femur may not only come to rest directly above 
the cotyloid cavity by a secondary displacement forward and inward ; 
it may also reach nearly the same point by a secondary displacement 
outward and backward from a primary dislocation forward upon the 
pubis. The distinction between the two is radical, for in the former 
the root of the Y-ligament lies on the inner side of the head, which 
must be returned to its socket by passing backward behind the ace- 
tabulum ; and in the latter the Y-ligament lies to its outer side and 
the head must be returned along the front or inner side of the acetab- 
ulum. There is still a third way in which the head may be placed 
above the acetabulum, although at a somewhat lower level, and that is 
by direct displacement upward, with rupture of the upper part of the 
capsule and of the Y-ligament, but this is extremely rare. 

The dislocations forward (or inward) and upward and inward and 
downward offer no difficulties in classification ; each has its character- 
istic symptoms, although the perineal variety of the latter is somewhat 
sharply distinguished from the obturator or thyroid variety by the 
greater flexion and abduction of the limb. Bigelow thinks the supra- 
pubic can be produced by a secondary displacement upward after the 
head has escaped at the lower part of the capsule during flexion of the 
limb, in a similar manner and by the same mechanism (lowering of the 
knee) as a secondary " iliac " dislocation is produced from a primary 
" isehiatic" one. In short, he thinks {Lancet, 1878) that in most cases 
the head of the femur escapes over the lower margin of the acetabulum 
and then passes upward as the limb is lowered, and either behind or 
in front of the acetabulum according as the limb is adducted or 
abducted, and upon this theory he bases a simple rule of treatment 
applicable to both anterior and posterior dislocations, namely, flex the 
limb at a right angle to bring the head below the socket, and then lift 
it into place. 

Finally, the head may be displaced downward upon the adjoining 
branch of the ischium, and rest there (subcotyloid) ; the position is one 
from which the head can be easily displaced backward or forward, and 
the dislocation thereby transformed into a dorsal or obturator. 

The distinction between the two backward forms, upon the dorsum 
ilii and toward the sciatic notch, wdiich has already been abandoned by 
eminent surgeons (Bigelow, Erichsen, Albert), does not appear to de- 
serve to be retained, except, perhaps, to establish corresponding vari- 
eties in the group ; and the anterior oblique, everted dorsal, and supra- 
spinous clearly belong in the same class by their mode of production 
and treatment. The class of supracotyloid dislocations, made by some 
writers to contain the two last mentioned, the rare dislocations directly 
upward, and some of the suprapubic, will be limited to those in which 
the head appears to have moved directly upward. The corresponding- 
class and term of " subcotyloid " must be retained for the rare dislo- 
cations downward "upon the tuberosity of the ischium." 



750 DISLOCATIONS. 

The terms upward and downward must not be taken too literally. 
They appear to have been rather carelessly used at first without strict 
regard to the normal position of the pelvis. When the body is upright, 
the upper border of the symphysis pubis lies a little below the level 
of the centre of the cotyloid cavity, and the tuberosity of the ischium 
lies not directly below this cavity, but below and behind. The classi- 
fication, then, which will here be used is as follows : 

f dorsal, comprising the " iliac " and " ischiatic," or 

those " upon the dorsum ilii " and " into the 

tv , .. , , i ischiatic notch" of the writers. 

Dislocation backward -{ eyerted ^^ comprising the anterior oblique> 

''supraspinous," and some of the "supracoty- 
[ loid." 
Dislocations downward f obturator, 
and inward \ perineal. 

Dislocations forward ) , . f ^P^neal. 

i i v suprapubic < pubic, 

and upward i ( Lrapelvic. 

Dislocations directly upward (supracotyloid or subspinous). 
Dislocations downward on the tuberosity of the ischium. 

As in the classification of dislocations of the shoulder, the names of 
the principal groups indicate the direction of the primary displacement 
and, consequently, the position of the rent in the capsule, and the 
names of the varieties show either the place at which the head of the 
femur comes to rest or the special symptomatic feature which marks 
the variety. 

BACKWARD DISLOCATIONS. 

1. Dorsal. 

2. Everted dorsal. 

In this class of dislocations the head of the femur in leaving the 
cotyloid cavity passes over its posterior margin at a higher or lower 
point while the limb is flexed, adducted, and rotated inward. In the 
great majority of cases the limb preserves this attitude, and the head 
rests not far from and behind, or behind and above, the margin of the 
acetabulum, between it and the great sciatic notch, or it may lie a 
little higher upon the concave surface of the ilium ; these constitute 
the dorsal variety, and include the " iliac " and " ischiatic " of other 
writers. In other cases external rotation of the limb takes place with 
or without abduction and extension ; in the latter case the limb crosses 
the opposite thigh and the toes are everted, the head of the femur lies 
above the socket, and the lower part of the neck corresponds to the 
upper and posterior margin of the acetabulum, the anterior oblique 
variety ; in the former case (with abduction and extension) the outer 
branch of the Y-ligament is ruptured, the head of the femur lies 
above the socket, and the everted limb lies parallel to its fellow, or 
slightly abducted — the everted dorsal variety. The class includes all 
the backward dislocations of other authors, and most of those that 
have sometimes been grouped under the term " supracotyloid." 



BACKWARD DISLOCATIONS OF THE HIP. 751 

1. Dorsal Dislocations. 

In these dislocation s, which are by far the most common of all dis- 
locations of the hip, the head of the femur lies behind and above the 
cotyloid cavity, either close to and overlapping its edge (Malgaigne's 
" incomplete " form) or further away upon the ilium. It may pass 
below the obturator internns and rise behind it, or between it and the 
pyriformis, or above the latter, or both muscles may be completely 
torn across. The group, therefore, includes the dislocations "upon 
the dorsum ilii " and those " into the ischiatic notch " of Cooper, or 
the " dorsal " and the " dorsal below the tendon " of Bigelow\s first 
classification, or the "iliac" and "ischiatic" of others. 

Causes. Dorsal dislocations are commonly caused by violence that 
approximates the knee and the pelvis while the thigh is flexed, 
adducted, and rotated inward, as in a fall from a height, or in the fall 
of a heavy body upon the back of the patient while he is stooping for- 
ward. Less frequently the dislocation is produced mainly or solely 
by flexion, adduction, and inward rotation, one of the three move- 
ments being exaggerated. Thus, in a case reported by Moffat, 1 the 
patient was drawing a railway carriage along the track ; he fell for- 
ward and rolled upon his back outside the rail to escape the car, but, 
as it passed, the end of the footboard caught his leg and bent it upon 
and across his belly (flexion and adduction). The car had to be raised 
with a jack-screw to free him, and when released he was lying upon 
his back with the limb in the position described. When examined at 
the hospital, the thigh was slightly flexed and rotated inward, the toes 
overlapping those of the other foot. 

In a case reported by Dupuytren, exaggerated adduction appears to 
have been the chief factor. A delicate man, twenty-one years old, 
was thrown, while wrestling, upon his left side, and in the fall the left 
thigh was forcibly carried across the front of the other by contact of 
the side of the knee with the ground. In a case observed by Mal- 
gaigne, and in another quoted by him from Mercier, exaggerated 
inward rotation appeared to be the principal cause ; both patients were 
women who slipped and twisted the foot inward while walking. 

A case, exceptional not only by its mode of production but also by 
the age of the patient, was reported by Bartels and has been referred 
to above. The patient was a child eleven months old, and the dislo- 
cation was caused by the effort of a shoemaker to put on its shoe while 
it was sitting on its nurse's knee. 

In two cases in which the head was split into two pieces, one of 
which remained in the socket attached to the ligamentum teres, it is 
evident that the flexion, adduction, and rotation were not carried far 
enough to turn the head out of the socket, and the dislocation, strictly 
speaking, was a complication of a fracture of the head produced by 
violent pressure of the inner segment against the outer and upper 
margin of the cavity; in like manner the dislocation may be facili- 
tated by the breaking off of a considerable portion of the acetabular 
ring. There is reason to think that some dislocations are produced in 

1 Moflat : Lancet, 1878, vol. ii. p. 251. 



7o^ DISLOCATIONS. 

this manner by violence acting directly upon the upper part of the 
thigh, as in the passage across it of the wheel of a heavy wagon. 

It is by no means uncommon for a dorsal dislocation to be produced 
by the transformation of one downward and inward (obturator) during 
manipulations made to effect reduction, the head passing below and be- 
hind the acetabulum during flexion and adduction of the limb, and, in 
like manner, a dorsal may be transformed into an obturator dislocation. 
Occasionally dorsal dislocation takes place gradually while the 
patient is confined to bed by illness, especially by acute articular rheu- 
matism and the infectious or eruptive fevers. These " spontaneous " 
dislocations are considered in Chapter LIIL 

Pathology. The condition of the capsule and of the muscles about 
the joint and the position of the head of the femur have been clearly 
shown by direct examination of a considerable number of specimens 
of recent dislocation, and by old ones, and by experiment upon the 
cadaver. Among the autopsies of fresh dislocations recently reported 
may be mentioned those by Moxon, 1 MacCormac, 2 Adams, 3 Morris, 4 
Lee, 5 Humphry 6 three cases, Rutherford, 7 Stimson, 8 and Walker. 9 

The capsule is torn always in its lower posterior part, and usually 
also in its under part, but the rent varies greatly in extent and shape. 
Frequently it lies about midway between the upper and lower posterior 
insertions of the capsule ; sometimes the capsule is torn away from the 
femur, and, rarely, away from the acetabulum. 

In Morris's, Lee's, and Walker's cases the conditions were exceptional ; 
in the former (Fig. 336) " the capsule was ruptured on its lower and in- 
ner side, and was clearly peeled up from off the back of the neck of the 
femur as far as the digital fossa. . The rent 
Fig. 336. commenced below the pectineo-femoral band, 

midway between the acetabulum and the femur 
and ran (1) outward and backward to the neck 
of the latter, which it reached just above and 
behind the small trochanter, and (2) inward 
and backward across the thin portion of the 
capsule toward the acetabulum, which it nearly 
reached a little behind the ischial border of the 
cotyloid notch. It thus formed tw r o sides of 
Morris's case of dorsal disio- ^ open ing which was made quadrilateral 

cation ; lemur flexed and ar> © 1 © i 

ducted to show the rent in the in form by the detachment of the flap from the 
capsule. back of the femoral neck." Evidently the 

head had escaped downward. 
In Lee's case the capsule was " freely lacerated all around, a small 
portion remaining attached to the femur in front and behind." This 
w r as, therefore, an " irregular " dislocation, and to the extensive lacera- 
tion of the capsule corresponded a variation in the symptoms which 

1 Moxon : Medical Times and Gazette. 1872, vol. i. p. 96. 

2 MacCormac: St. Thomas's Hospital Eeports, 1871, vol. ii. p. 143. 

3 Adams: Transactions of the Pathological Society of London, 1870, vol. xxi. p. 305. 
1 Morris: Medico-Chirnrgical Transactions, 1877, vol. lx. p. 161. 

5 Lee: St. George's Hospital Reports, 1872-74, vol. vii. p. 169. 

6 Humphry: Lancet. 1886, vol. ii. p. 1011. 

7 Rutherford : Glasgow Medical Journal, May, 1889. 

8 Stimson : New York Medical Journal, August 10, 1889. p. 163. 

9 Walker: Detroit Lancet, Julv, 1879. 




BACKWARD DISLOCATIONS OF THE HIP. 753 

fully corroborates Bigelow's views ; the report says : " Two of the 
main signs of dislocation were absent, namely, the advanced position 
of the knee with the foot resting upon the opposite one, and marked 
shortening." The head of the femur was below the pyriformis muscle 
and immediately behind the acetabulum. 

In Walker's the posterior rim of the acetabulum had been broken off, 
the posterior half of the capsule torn away, and the bone displaced to 
an unusual distance. The violence had been very great. 

The preservation of the anterior portion of the capsule, the ilio- 
femoral ligament, is constant, as has been said, in the cases which 
Bigelow terms " regular," those which are marked by the common 
and characteristic symptoms of the dislocation, and, as he also pointed 
out, the strong portion of the capsule at its upper and posterior part is 
also usually untorn and opposes the ascent of the head upon the ilium. 

The ligamentum teres is usually torn from its attachment to the 
femur, but sometimes is ruptured. 

Of the muscles, the quadratus femoris is usually completely torn 
across, but sometimes (Humphry's third case) is intact; the gemelli 
commonly are torn, but the obturator internus which is so closely asso- 
ciated with them frequently escapes or is only partly lacerated, prob- 
ably because of its greater length. The pyriformis and obturator 
externus are sometimes torn partly or entirely across ; the glutei 
usually escape injury entirely or are only slightly lacerated. 

The head of the femur may lie close to the margin of the acetabu- 
lum, even overlapping the cavity, or it may be displaced to a variable 
distance backward or backward and up- 
ward. The lowest point at which its Fig. 337. 
centre rests is the base of the spine 
of the ischium (Adams 1 and Quain 2 ) Pyrifo 
overlapping both sciatic notches ; and 
the highest, except perhaps in excep- 
tional cases, appears to be opposite the 
apex of the great sciatic notch, which, 
in the recumbent position, is directly 
below the anterior superior spine of the 
ilium, the line uniting the two passing 
about an inch above the margin of the 
cotyloid cavity. Fifty years ago Quain _ , 

i - ,-11 i ,i Dislocation below and then behind and 

demonstrated by autopsy the error above the obturator internus. 

contained in the name given by Sir 

Astley Cooper to the lower form of dislocation " into the sciatic notch," 
and formally called attention to it ; and a few years later Malgaigne 
showed that the head of the bone was much less upon the ilium in the 
higher form than was supposed, and further that in many, perhaps a 
majority, of the dislocations " upon the dorsum ilii " the femur left 
the socket at its lower posterior part and subsequently passed upward, 
so that in such cases the primary dislocation was u ischiatic," and tin 1 
" iliac" was secondary. This view lias been amply confirmed. In 11 

1 Adams : Loc cit. 

2 Quain: Medico-Chinirgieal Transactions. 1848, vol. xxxi. p, 337, 

48 




754 



DISLOCATIONS. 



specimen? of old dislocations which Malgaigne examined, the head of 
the femur rose in 5 only to the level of a line drawn from the anterior 
superior spine of the ilium to the apex of the great sciatic notch, in 2 
it rose half a centimetre above this line, in 2 one centimetre, in 1 one 
and a half centimetre^, and in 1 two centimetres. There is no reason 
to suppose that in old dislocations the head is at a lower level than in 
recent ones, indeed it is probably somewhat higher. 

When the head of the femur leaves the socket at its lower part it 
passes usually below the obturator internus and then rises behind it. 
so that this muscle is interposed between it and the acetabulum (Fig. 
337). Or it may lie immediately beneath the obturator intemns and 
press it forcibly upward, as in Adams's case (Fig. 338), which remained 
unreduced until the patient's death on the fourteenth day. and in which 
the muscle was so tightly stretched over the upper part of the head 
that a deep groove had formed in the articular cartilage of the latter 
exactlv corresponding in size and direction to the tendon ; the head 
rested on the spine of the ischium, and the obturator externus and 
quadratus femoris were ruptured. Or the head may pass above the 
obturator internus, between it and the pyriformis, as in MacCormac's 
case i Fig. 339 ), in which it rested " behind the acetabular ridge opposite 



Fig. 33S. 



Fig. 339. 




Adams's case : a. head of femur : 6, obturator 
externus ruptured: c. quadratus femoris rup- 
tured: d. sciatic nerve. 




MaeCormacs specimen of recent dorsal dis- 
location. The head of the femur lies just be- 
hind the acetabulum, below the pyriformis, 
and above the obturator internus and the torn 
gemellus muscles. 



the middle and upper part of the ^reat ischiatic foramen, behind the pos- 
terior border of the gluteus medius, and only covered by the gluteus 
maximus and the integument." This is an example of a real primary 
"iliac dislocation, and the rent in the capsule was "merely on the 
back part, and the neck was as it were locked over the acetabular ridge, 
and the strong anterior part of the capsule was tightly stretched."' 

The edge of the acetabulum is sometime- chipped, and in two of 
the case- above quoted Quain, Morris) there was a fracture through 



BACKWARD DISLOCATIONS OF THE HIP. 755 

the ilium into the cotyloid cavity, and in the latter there was also a 
fracture of the ramus of the ischium. In both cases the injury was 
caused by great violence. 

In a case reported by Birkett l the head of the femur was split ver- 
tically, the inner half remaining in the acetabulum and still attached 
to the ligamentum teres, and the other, continuous with the neck, 
being displaced backward above the obturator internus. A similar 
case, quoted above among compound dislocations, p. 774, was reported 
by Moxon ; and in another reported by Riedel 2 the head and neck were 
split longitudinally, both fragments being displaced from the socket. 
Crile 3 reported a case of fracture of the posterior third of the head 
and of the posterior half of the rim of the acetabulum. In my case 
the head of the femur was deeply indented, apparently by contact with 
an osteophyte close behind the rim of the acetabulum, and a portion 
of the labrum cartilagineum had been broken off. In a case seen by 
Lossen 4 the neck of the femur had been broken at the moment of dis- 
location, but doubtless after the head of the bone had left the socket. 
In several reported cases the neck has been broken during an attempt 
to reduce, and in a few in which fracture has been recognized it has 
remained uncertain whether it occurred simultaneously with the dislo- 
cation or was caused by the surgeon. (See Chapter LIII.) 

The sciatic nerve commonly lies behind the head of the femur and 
at the most is only slightly pressed upon, but in Quain's case it was 
stretched over the neck of the femur. 

Symptoms. The patient is unable to bear his weight upon or volun- 
tarily to move his injured limb ; if he stands upright it shows moder- 
ate flexion and adduction, marked inversion, and more or less shorten- 
ing, the toes resting on those of the other foot. When he is placed 
upon his back the apparent adduction and flexion are increased, the 
knee resting just above the other patella or crossing the thigh at a 
higher point. The contours of the outer and posterior regions of the 
hip are changed by loss of the normal depression behind the trochanter, 
elevation of the gluteal fold, and abnormal fulness due to the approxi- 
mation of the insertions of the gluteal muscles. The trochanter rises 
to a variable distance above the line drawn from the anterior superior 
spine of the ilium to the tuberosity of the ischium, and its distance 
from the first-named prominence is increased. The head of the femur 
can be obscurely felt through the gluteus maximus and recognized by 
its movements when the limb is flexed or rotated. The empty socket 
cannot be felt from in front, because it is covered by the anterior por- 
tion of the capsule and the psoas and iliacus, but the depressibility 
of the soft parts in Scarpa's space is as great as, or greater than, that 
on the opposite side, whereas in fracture of the neck of the femur this 
depressibility is diminished. 

The limb can be still further adducted and flexed, but it cannot be 
abducted or rotated outward. The apparent shortening varies greatly 
in degree in different cases, and the actual shortening cannot always be 

1 Birkett : Medico-Chirurgieal Transactions, 1869, vol. lii. p. 133. 

2 Eiedel : Beilage zum Centralbl. fur Chir., 1885, p. 92. 

3 Crile : Annals of Surgery, May, 1891. * Lossen: Deutsche Chir., Lief. 65, p. 55. 



756 DISLOCATIONS. 

determined with accuracy because of the difficulty in placing the limbs 
symmetrically. Concerning this shortening the most contradictory 
statements have been made ; some surgeons, relying solely upon the 





Fig. 


340. 




h:[ !{| 


5 


^■fer 






/ 






HfiL ; M& 








I 








fl^HS 









Dorsal dislocation of the hip. 

appearance of the limb and seeing that the knee lay well above the 
opposite one, have described the shortening as great ; others, looking 
only to the new relations of the bones as shown upon the skeleton, 
have described the shortening as moderate or even as absent in the 
lower forms. The error in the first arises from not taking into account 
the effect of adduction to create an apparent shortening of the adducted 
limb when compared with its non-adducted, still more with its abducted, 
fellow ; that in the second arises from considering the question only 



BACKWARD DISLOCATIONS OF THE HIP. 1-u 

with reference to the position of extension. If the head of the femur 
is displaced backward toward the spine of the ischium, the length of 
the limb measured in extension (if that is possible) from the anterior 
superior spine of the ilium to the knee or ankle will not be diminished, 
for the movement backward of the head has been at right angles to the 
line of measurement and has not brought the knee any nearer to the 
pelvis ; but if the measurement is made while the thigh is flexed at 
a right angle the measured length will be less by about two inches than 
that of the other limb in the same position, for now the measured line 
is nearly parallel to the direction of displacement. When the head is 
displaced upward as well as backward the difference in the amount of 
shortening in these two positions of the limb is much less, for the direc- 
tion of the displacement deviates at about the same angle from the 
measured line in each attitude. Of course, in each limb the measured 
length is less when the thigh is flexed, but the difference in the com- 
parative measurements of the two limbs is not affected in the high dis- 
locations and is greatly affected in the low ones. In making measure- 
ments the two limbs must be symmetrically placed as regards flexion 
and adduction, and the fixed adduction of the injured limb sometimes 
interferes seriously with the accomplishment of this condition, for its 
knee occupies the position to which the other one should be brought, 
and, therefore, an equal adduction cannot be given to the sound limb 
without carrying its knee across at a higher or lower level, and thus 
giving it an unsymmetrical flexion. It must also be remembered that 
apparent symmetry of position is not sufficient, the symmetry must be 
real in that the angles of flexion and adduction on the pelvis are the 
same. Fortunately the exact determination of the shortening is not 
necessary to the diagnosis of the dislocation. 

When the head passes below the tendon of the obturator internus 
and does not secondarily rise upon the ilium, the inversion and flexion 
of the limb are greater than when the head comes to rest at a higher 
point, and may be so great that the limb crosses the opposite thigh as 
high as its middle. The flexion may be so masked by the tilting of the 
pelvis that the thigh will lie nearly along-side the other, parallel to 
the long axis of the body, but the condition can be recognized by 
attention to the compensatory curve (lordosis) of the lumbar vertebra? ; 
indeed, Syme 1 said he made the diagnosis of ischiatic dislocation with- 
out other handling of the patient than that necessary to recognize the 
lordosis. 

The cause of the comparative fixation of the limb, of its attitude, 
and of the loss of even passive abduction and external rotation was 
first clearly shown by Bigelow, in his classical monograph upon the 
Hip. Others had recognized, in a measure, the part taken by the 
strong anterior portion of the capsule in determining the attitude of 
the limb, but he was the first to study the subject in all its bearings 
and to present a complete account of the relations and influences oi' the 
Y-ligament in all forms of dislocation, one which was at once and every- 
where accepted and has been made the basis of the present methods of 
reduction. He says, 2 "The inversion is chiefly due to the outer branch 

1 Syme: London and Edinburgh Monthly Journal, 1S43, vol. iii. p. 49S. 

2 Bigelow : The Hip, p. 38. . ,. 



758 DISLOCATIOXS. 

of the Y-ligament, as is shown by the fact that the characteristic sign 
disappears when this branch is divided." 

Diagnosis. The recognition of the character of the injury is rarely 
difficult. The group of prominent symptoms — loss of function ; adduc- 
tion, inversion, and flexion of the limb ; resistance to abduction, exten- 
sion, and outward rotation ; elevation of the trochanter above Xelaton's 
line — are not found in any other affection except perhaps hip-joint dis- 
ease of long standing. The mistake most frequently made is that of 
confounding it with a fracture of the neck of the femur, or, to speak 
more definitely, is that of supposing a fracture of the neck to be a 
dislocation. I have met with several instances of this, some of which 
led to litigation. The differences between the symptoms of the two 
injuries are striking and usually sufficient to make the mistake impos- 
sible if ordinary attention is paid to them ; the fixity of the limb in dis- 
location, with the knee thrown forward and inward against or upon the 
opposite thigh, the prominence of the trochanter, and, usually, its 
increased distance from the anterior superior spine of the ilium, con- 
trast strongly with the straight, everted, powerless limb and flattened 
hip of fracture of the neck. Fractures with inversion and dislocations 
with e version are entirely exceptional. When the two injuries have 
coexisted the diagnosis has sometimes been made by recognizing that 
the head, which could be felt out of its place, did not share in the 
movements communicated to the shaft, 1 and sometimes by the splitting 
and enlargement of the great trochanter. 

2. Everted Dorsal Dislocations. 

In this class, of which there are but few recorded cases, are here 
included Bigelow's anterior oblique, everted dorsal, and some of the 
supraspinous. It is characterized, as the name indicates, by eversion 
of the limb in place of the inward rotation which is so prominent a 
feature of the common dorsal dislocation, and this symptom is due in 
all cases, except perhaps the very rare anterior oblique, to rupture of 
the outer branch of the Y-ligament. In the supraspinous variety the 
head of the bone lies above the anterior inferior spinous process of the 
ilium in the notch between it and the superior spine. 

Although occasional cases had been previously reported, the variety 
was not described by systematic writers before Bigelow, and was not 
even mentioned by Malgaigne, although possibly one or two of the 
cases classed by him as supracotyloid may have been of this kind. 
In a paper by'Blasius 2 on supracotyloid dislocations several cases of 
this variety (everted dorsal) are included, together with others in which 
the head had reached nearly the same position by passing outward after 
primary dislocation forward and upward upon the pubis, and a few 
in which the dislocation was primarily directed upward. The same 
grouping has been followed by other writers, and in no reported case 
previous to 1850 does it appear to have been recognized that the head 
had reached this position by a secondary displacement after dislocation 

1 Koch: Berlin, klin. Wochenschrift, 1882, p. 492. 

2 Blasius : Arch, fur klin. Chir., 1874, vol. xvi. p. 207. 



BACKWARD DISLOCATIONS OF THE HIP. 759 

backward and upward. Blasius's paper, although published in 1874, 
must be classed with those of an earlier period, for it is really the 
republication by his son in a graduating thesis of researches made 
some time earlier, and it makes no mention of Bigelow's work. It 
is, in one respect, a publication to be regretted, for the authority of 
its writer and its date combine to further the acceptance without exami- 
nation of the grouping, or classification, which cannot properly be 
accepted in view of the important pathological differences between the 
individual cases of which it is made up. 

Cases reported before 1850 and quoted as of this kind by Bigelow 
and as possibly such in my first edition, appear to me to be more prob- 
ably dislocations directly upward by hyperextension of the limb ; I 
have recently seen such a one the symptoms of which closely resem- 
bled those quoted. (See Upward Dislocations.) 

In 1850 the possibility of the production of this form by trans- 
formation of a dorsal dislocation was shown in an attempt made 
in the New York Hospital to reduce a dislocation " into the sciatic 
notch." The case is reported by Lente; 1 after traction had been 
made and suddenly relaxed the thigh was abducted and rotated 
outward, and this brought the head of the femur above the acetab- 
ulum, and below the anterior superior spinous process ; the shorten- 
ing was then about two inches ; the limb very much rotated out- 
ward, the rotundity of the hip greater than that of the other, and 
the trochanter major one inch further from the anterior superior 
spinous process. 

Five years later Van Buren 2 observed in the same hospital a case 
which, so far as I know, is the first in which the absence of inversion 
and marked adduction was noted in a case recognized as a dorsal dis- 
location. The limb " was shortened about an inch ; the foot and leg 
were slightly everted. This eversion, it was afterward ascertained, 
could be readily increased by manipulation ; but there was an evident 
obstacle at the hip to inversion of the foot. The knee was slightly 
flexed, so that the width of the hand could be readily passed between 
its popliteal aspect and the surface of the bed. The obliquity of the 
femur toward its fellow was very slightly increased. Upon the front 
of the thigh at its upper third a very manifest concavity or sinking in 
was noticeable, the usual anterior convexity of the limb being lost. 
The trochanter was about an inch and a half behind and above its usual 
position, and, during etherization, it was quite movable on attempting 
rotation of the limb. Finally, the head of the femur could be felt 
obscurely but pretty certainly rotating in the ischiatic notch, low down, 
and in contact with its posterior margin. The anterior convexity of 
the spine at the loins was also much increased, so that under ether 
more than the width of the hand could be passed between it and the 
surface of the bed. Thus the case presented all the classical features 
of luxation into the ischiatic notch, and more than usually well marked, 
with the exception of adduction of the lower end of the femur and 

1 Lente: New York Journal of Medicine, 1850, p. 314. 

'-' Van Buren: New York Medical Times, 1856, vol. v. p. 126, and reprinted m his Con- 
tributions to Practical Surgery, p. 157. 



760 DISLOCATIONS. 

inversion of the foot." After several failures to reduce bv manipula- 
tion and traction doAvnward, reduction was effected by traction while 
the limb was flexed at right angles to the pelvis, followed by abduction 
and extension. 

In 1864 Symes 1 reported a case, and suggested for the variety the 
name of " dorsal with eversion." This was subsequent to Bigelow's 
researches but previous to his publication of them except in his lec- 
tures. The limb was shortened two inches, the foot extremely everted, 
the buttock flattened, and the head of the femur two inches below the 
anterior superior spine of the ilium. By flexion of the limb the dislo- 
cation was made dorsal, and a feature of special interest is that then, 
as the limb lay untouched upon the table, eversion gradually took place 
under the influence of gravity, and the head returned to its former 
place. 

In 1874 Kocher 2 observed a similar case in a woman, forty-nine 
years old ; the limb was fully extended, markedly everted, and short- 
ened three centimetres ; the head could be felt below and to the outer 
side of the anterior superior spine of the ilium. By flexion and inward 
rotation the dislocation became dorsal with the characteristic symp- 
toms, and then by extension and outward rotation the original symp- 
toms were reproduced. 

Pathology. In a case which I reported to the New York Surgical 
Society, December, 1887, and January, 1888, 3 the head could be dis- 
tinctly felt below and rather to the outer side of the anterior superior 
spinous process ; the outer branch of the Y-ligament was ruptured and 
the muscles behind the trochanter extensively lacerated. Complete 
reduction was prevented by interposition of the anteroinferior part of 
the capsule. 

Van Buren's case, and a very similar one reported by Annandale, 4 
show that the head may lie much further to the outer side and lower. 

Bigelow's experiments show that this eversion depends upon the 
rupture of the outer branch of the Y-ligament. The head of the 
femur escapes at the back of the joint while the limb is flexed, 
adducted, and rotated inward, and then by external rotation the outer 
branch is torn ; if, then, the head remains in its position opposite or 
below the sciatic notch, the position and symptoms are such as are 
noted in Van Buren's and Annandale's cases, the flexion and slight 
adduction being due to the remaining untorn branch of the ligament. 
The change in the position of the head noted in the other cases Bige- 
low was able to reproduce experimentally from a common dorsal dis- 
location by carrying the limb " across the symphysis, so that the outer 
and convex surface of the socket shall correspond to the hollow beneath 
the neck of the femur. With some force the thigh can now be everted, 
and afterward brought down across the upper part of its fellow." 
(This is the form to which he gave the name " anterior oblique.") 
" If, in this position, it is desired to bring the limb toward a perpen- 
dicular, the outer branch of the Y-ligament must be ruptured. Thus 

1 Symes : Dublin Quarterly Journal of the Medical Sciences, 1864, vol. xxxviii. p. 272. 

2 Kocher: Volkraann's Sammlung klin. Vortrage. No. 83, p. 631. 

3 Stimson : New York Medical Journal, January and February, 1888. 

4 Annandale: Lancet, 1876, vol. i. p. 208. 



BACKWARD DISLOCATIONS OF THE HIP. 



761 



liberated, it hangs suspended by the inner ligament, and becomes capa- 
ble of lateral motion and of rotation ; and this is probably the con- 
dition under which supraspinous luxation, although rare, usually 
occurs." 

Fig. 341 shows in the dotted lines the head of the femur thus hooked 
over the remaining part of the ligament. 

The anterior oblique is a variety which I feel some hesitation in pre- 
serving, because Bigelow appears to have observed it only in experi- 
ments upon the cadaver, and to have known of only one recorded 
case 2 in which the attitude resembled that found in his experiments. 
The specimen in that case is represented in Fig. 342. The mode of 
production has been quoted in the preceding paragraph. The Y-liga- 
ment is untorn. 



Fig. 341. 



Fig. 342. 





Supraspinous dislocation. When the femur takes the 
position indicated by the dotted line, only the inner 
branch of the Y-ligament remains untorn. (Bigelow.) 



Anterior oblique dislocation. 
Oldnow's case. 



Symptoms. The symptoms of the everted dorsal may be the same 
as those of the common dorsal dislocation, with the exception that 
there is marked or slight e version of the limb instead of inversion ; or, 
if the head of the femur has moved forward above the anterior inferior 
spinous process, they may differ widely, for the limb is then shortened 
about two inches, slightly abducted, more or less everted, and fully 
extended. In my case, a woman fifty-five years of age, the limb was 
parallel with the other and so far everted that the foot rested on its 
outer border; it could be adducted and flexed but not abducted or 
rotated inward. Shortening one and three-quarter inches. By flex- 
ing and adducting the limb and then rotating inward the attitude and 
appearance became that of the common dorsal variety. Reduction 
1 Oldnow: Guy's Hospital Reports, 1836, vol. i. p. 97. 



762 DISLOCATIONS. 

was made by flexing to a right angle, rotating inward, and then lift- 
ing. The patient died about a month after the accident (associated 
injuries and phthisis). The eversion of the limb is liable to lead 
to the mistake of supposing the injury to be a fracture of the neck 
of the femur, especially in the cases in which the limb is also 
extended. The greater fixation of the limb and the recognition of 
the position of the head and of the continuity with the shaft, as shown 
by its sharing in the movements communicated to the latter, will estab- 
lish the diagnosis. 

The rupture of the outer branch of the Y-ligament is the explana- 
tion of the inability noted in some of the cases to reduce by manipu- 
lation alone; traction in the flexed position is needed to bring the head 
forward into the socket ; abduction fails to do it because of the loss 
of the support of the outer branch of the ligament. 

Treatment of Backward Dislocations. 

The method of reduction so long in use, and which left so many 
dislocated hips unreduced, that in which it was sought to draw the 
bone into place by traction upon it with compound pulleys while the 
limb was almost fully extended, has at last been abandoned in favor 
of the methods of simple manipulation or of moderate traction in the 
flexed position, or of a combination of the two. The advantages of 
the flexed position, the possibility of reducing by the aid of moderate 
traction when the thigh is flexed at a right angle with the trunk, were 
repeatedly pointed out by different writers during the last century and 
the first half of the present one (see Chapter XXXIIL), and the pos- 
sibility of reducing by manipulation alone (flexion, outward rotation, 
and abduction) was also demonstrated, but neither seems to have had 
any influence in modifying the general practice, although some sur- 
geons, notably Prof. Nathan Smith of Xew Haven, taught and habit- 
ually practised traction with the limb flexed at a right angle, and he 
also, in 1831, formulated a method by manipulation alone. 

Despres, 1 in 1835, independently formulated the method by flexion 
and outward rotation; and Reid, 2 in 1851, did the same, preceding the 
flexion with marked adduction ; but they assumed that the principal 
obstacle to reduction lay in the resistance of the muscles, and their 
manipulations were designed to overcome or avoid this. 

Bigelow 3 quotes Smith's description of this method by manipulation 
from his Medical and Surgical Memoirs, edited in 1831 by his son, 
Nathan R. Smith, as follows : " The first effort which the operator 
makes is to flex the leg upon the thigh, in order to make the leg a lever 
with which he may operate on the thigh bone. The next movement 
is a gentle rotation of the thigh outward, by inclining the foot toward 
the ground and rotating the knee outward. Next, the thigh is to be 
slightly abducted by pressing the knee directly outward. Lastly, the 
surgeon freely flexes the thigh upon the pelvis by thrusting the knee 

1 Despres : Bull, de la Soc. Anatomique, September, 1835, p. 4. 

2 Reid : Buffalo Medical Journal, August. 1851. 

3 Bigelow: Lancet, 1878, vol. i. p. 861. 



BACKWARD DISLOCATIONS OF THE HIP. 763 

upward toward the face of the patient, and at the same moment the 
abduction is to be increased." Bigelow adds, " this covers the ground 
of priority of invention. It belongs to Nathan Smith. ... In 
1835, Despres, and in 1851, Reid, of Rochester, enunciated the same 
views ; the practice was good, but both Prof. Smith and Dr. Reid based 
the method upon and sought its mechanism in its erroneous theory of 
muscular resistance." 

After 1850 the attention of surgeons and anatomists began to be 
directed more specifically to the opposition offered by the untorn por- 
tions of the capsule and to the position of the rent in it, and many 
experiments were made upon the cadaver to obtain a more accurate 
knowledge of the matter. Among these may be mentioned those of 
Meyer, 1 Gunn, 2 Roser, 3 Bigelow, 4 Gelle, 5 Busch, 6 and Tillaux. 7 Of 
these Bigelow's researches were by far the most complete and accurate, 
and to his classical work must be referred the popularization and gen- 
eral acceptance of the views now held and the methods of treatment 
based upon them. The importance of the anterior portion of the cap- 
sule, the Y-ligament, had indeed been specifically pointed out by one or 
two earlier writers — it is mentioned in Hyrtl's Topographische Anato- 
mle, in Meyer's paper in 1850, and by von Pitha 8 in 1863 — -but Bigelow 
was the first to study its influence in detail, to show its constant action 
in all typical forms, and to base upon it methods of reduction for the 
different forms, and to him belongs the credit not only of independent 
discovery but also of the still more important benefit conferred by 
impressing the facts upon the profession by his careful, thorough in- 
vestigations and his clear exposition of the facts and principles. 9 

It is now generally recognized that the chief obstacle to reduction 
is created by the tension of the Y-ligament in the partly extended posi- 
tion of the limb, and that this is to be removed by flexion of the limb 
upon the trunk. At the same time the movement of flexion brings 
the head of the femur down along the back of the acetabulum so that 
it lies opposite the opening in the capsule if, as is usually the case, it 
has left the socket at its lower posterior part and has risen to a higher 
level by the subsequent extension of the limb, enlarging the rent 
upward in the movement ; if, more rarely, the head has left the socket 
at a higher level while the limb was only slightly flexed, this move- 
ment of flexion in reduction, unless carried beyond a right angle, does 
not place the head below the opening, or at least, if it does so, the 
movement enlarges the rent downward so that the way is still open 
for the return of the head to its place. Another reason for making 
this movement is found in some cases in the interposition of the obtu- 

1 H. Meyer: Zeitschrift fur rat. Med., 1850, vol. ix. p. 250. 

2 Gunn : Pe'nins, Journal of Medicine, 1853-4, vol. i. p. 97. 
;! Roser: Archiv fur phys. Heilkunde, 1857, vol. i. p. 42. 

4 Bigelow : The Hip, 1869. Experiments made in i860. 

5 Gelle : Arch. gen. de Med., 1861. 

6 Busch: Arch, fur klin. Chir., 1863, vol. iv. p. 11. 

7 Tillaux : Bull, de la Soc. de Chir., 1868, p. 274. 

8 Von Pitha: Pitha and Billroth's Chirurgie. vol. iv. part 2. B. p. 161. 

9 The claim of priority in the discovery of the part played by the anterior portion o\' 
the capsule made for Prof. Gunn, of Chicago, is, I think, sufficiently answered by Prof. 
Bigelow in a letter published in the Chicago Medical Examiner. January, 1870. p. 25. 



764 DISLOCATIOXS. 

rator interims between the head and the socket, the eases, so-called, of 
" dislocation below the tendon " in which the head has secondarily 
risen toward the dorsum ilii. During the movement the adduction and 
internal rotation of the limb are preserved or even somewhat increased 
in order to lift the head of the femur away from contact with the pelvis 
and from behind the projecting rim of the acetabulum. 

The directions given by Bigelow in his first publication 1 are as fol- 
lows : 

" By Traction. Lay the patient, when etherized, on his back upon 
the floor, bend the limb at the knee, flex the thigh upon the abdomen, 
ad duct and rotate it a little inward, to disengage the head of the bone 
from behind the socket. The Y-ligament is then relaxed. 

" If the bone can now be abducted beyond the perpendicular, the 
capsule and other tissues are probably so torn or relaxed that reduction 
may be accomplished without much difficulty ; the thigh need only be 
forcibly lifted or jerked toward the ceiling, with a little simultaneous 
circumduction or rotation outward, to direct the head of the bone 
toward the socket." 

In his later paper in the Lancet, 1878, he gives them more briefly 
in the following terms : 

" 1. Flex and forcibly lift. If this fails, 

" 2. Flex and lift while abducting. If this fails, it will be found 
that the rent in the capsule has been so enlarged that the first method 
may now prove successful." 

Bigelow adds to his first description three other methods of making 
the manipulation and applying the force, and, although the mechanism 
is the same in all, the multiplicity of the directions has been criticised 
by recent German writers, who seem to regard the four as essentially 
different from one another. 

Kocher, 1 after making this criticism, describes what he calls his own 
method, and this is quoted approvingly by Albert and Konig. Its 
identity with Bigelow's appears to me to be complete, although it com- 
bines his two methods by traction and by manipulation. It is as follows: 

1. Inward rotation to relax the capsule and lift the head from the 
posterior surface of the pelvis. 

2. Flexion, to a right angle and gently, preserving the existing 
adduction and inward rotation. 

3. Traction, to make the capsule tense, so that it can be utilized in 
the following movement, and to raise the head to the level of the 
acetabular margin, thus overcoming the action of gravity. 

-4. Outward rotation ; this makes the posterior part of the capsule 
and outer band of the Y-ligament tense, and turns the head forward 
into the socket. 

There are a number of practical points connected with the carrying 
out of these directions which require attention. The pelvis may need 
to be steadied or immobilized during traction, in order that the limb 
may not be too soon or unwittingly abducted, and this may be done 
either by the hands of assistants or by the pressure of the surgeon's 

1 Bigelow : Loc. cit., p. 46. 

2 Volkrnann's klinische Vortrage. Xo. 83. 



BACKWARD DISLOCATIONS OF THE HIP. 



765 



foot upoii the anterior superior spinous process of the ilium of the 
injured side while he is lifting the thigh. 

The traction upon the thigh may be made by the hands of the sur- 
geon, but if the patient is a muscular adult the force that can be thus 
exerted may be insufficient, and it can then be conveniently supple- 
mented by passing a bandage tied in a long loop under the patient's 
flexed knee and over the surgeon's shoulders ; this leaves his hands 
free to rotate the thigh by means of the leg. It is important to remem- 
ber that reduction is to be made by traction, not by manipulation, for 
if the thigh falls backward by its own weight or is pressed back by 
the surgeon while he is " manipulating " it may seriously change its 
relations with the tissues about it. 

Fig. 343. 




Reduction of dorsal dislocation of the hip by the weight of the limb. 

A much more convenient plan, one which I have habitually em- 
ployed for many years, 2 is to place the patient face downward upon a 
table with his legs projecting so far beyond the edge that the injured 
thigh hangs directly downward while the surgeon grasps the ankle, 
the knee being flexed at a right angle (Fig. 343). The other limb is 
held horizontal by an assistant, The weight of the limb now makes 
the needed traction in the desired direction, and the surgeon has only 
to wait for the muscles to relax and the bone to resume its place with- 

1 Stimson : New York Medical Journal, August 3, 1889. 



766 DISLOCATIONS. 

out further effort on his part than a slight rocking or rotation of the 
limb. Occasionally I have added the weight of a small sand-bag at 
the knee or have made sudden slight pressure at the same point. It 
will often succeed without anaesthesia and sometimes so quietly that 
there is no jar or sound indicating the return to place. In only two 
cases has it failed in my hands ; both were then reduced by traction in 
the axis of the partly flexed limb. I presume that in both the bone 
had left the socket at its upper posterior segment — " iliac " dislocation. 

If manipulation alone is used external rotation must be carefully 
avoided during the first steps, lest it should convert the dislocation into 
an everted dorsal by throwing the head forward above the socket ; and 
extreme flexion and abduction without simultaneous traction are also to 
be avoided, in order to escape the conversion of the dislocation into one 
upon the obturator foramen by the passage of the head below the socket. 

The everted dorsal dislocations are reduced after having first converted 
them into the dorsal form. This conversion is effected by flexion and 
inward rotation, with adduction, if necessary, to make room for the 
head of the bone to slide upon the ilium; the rupture of the outer 
branch of the Y-ligament deprives the operator of much of the advan- 
tage of rotation, and the dislocation must, therefore, be reduced by 
direct traction toward the socket, with local guidance of the head. In 
my own case, in which, after conversion into the dorsal form the 
tendency of the head again to pass forward above the acetabulum was 
very marked, outward rotation had to be carefully avoided. 

The possibility of fracturing the neck of the femur during manipu- 
lation must be borne in mind (see Chapter LIIL). 



CHAPTER LII. 

DISLOCATIONS OF THE HIP.— (Continued.) 

Dislocations Downward and Inward: Obturator, perineal — Forward and Up- 
ward : Suprapubic, iliopectineal — Upward : Subspinous, supracotyloid — ■ 
Downward on the Tuberosity of the Ischium. 

DISLOCATIONS DOWNWARD AND INWARD. 

1. Obturator or thyroid dislocations, or dislocations upon the 
thyroid foramen ; and 2, perineal dislocations. 

In this class of dislocations the head of the femur leaves the socket 
at its lower, or lower and inner, part, and passes forward and inward 
to rest upon the obturator foramen (obturator dislocation), or passes 
still further, and, crossing the ischio-pubic ramus, projects in the per- 
ineum (perineal dislocation). The limb is flexed, abducted, and usually 
rotated outward. 

Obturator or Thyroid Dislocations. 

These dislocations, although infrequent, are apparently the second in 
order of frequency of those of the hip, and it seems not improbable 
that this form, in part at least, is the first stage in the production of 
some of the suprapubic, and even some of the dorsal dislocations ; that is, 
the head of the bone, having left the socket at its lowest part in forced 
flexion of the limb, may either be turned backward behind the acetab- 
ulum by adduction, internal rotation, and diminution of the flexion, or 
forward and upward upon the pubis by external rotation and exten- 
sion ; the obturator form is produced by its passage more directly for- 
ward and inward upon the obturator foramen by abduction and 
external rotation. 

Cause. The commonest cause appears to be great violence acting 
upon the back of the pelvis while the limb is flexed and abducted, as 
in the fall of a heavy object upon the back of a man who is stooping 
forward with his legs separated. Simple abduction of the extended 
limb is apparently sufficient to produce the injury, as is shown by a 
case reported by Corne, 1 in which the thigh of a drunken soldier was 
forcibly abducted by his comrades. In a case reported by Keate, 2 and 
another by Barker, 3 the mechanism was apparently the same ; in the 
former the patient, while riding, fell into a ditch, his horse falling upon 
him and widely separating his legs ; the head of the femur lay close 
to the tuber ischii. In the latter the patient fell from a height of 
about thirty feet, striking upon a sandbank and having his legs widely 
separated ; both thighs were dislocated. 

1 Corne: Recueil de Mem. de Mod. Mil.. February. 1867, quoted by Lossen. 

2 Keate: London Medical Gazette, vol. x. p. L9, quoted by Bigelow. 

3 Barker: American Journal of the Medical Sciences, 1854, vol. xxvii. p. 412. 



67 



768 



DISLOCATIONS. 



Fig. 344. 



In another set of cases it is difficult to determine whether the cause 
has been direct impulsion of the head of the femur downward and 
inward by a force acting on the outer side of the great trochanter, or 
whether it has been exaggerated abduction by pressure forward of the 
outer part of the pelvis, as in a case reported by Treub, 1 in which a 
man while lying on his face was run over by a wagon, the wheels pass- 
ing obliquely across his left hip at the level of the trochanter and the 
pelvis from left to right, and received a dislocation of the left hip. 

Pathology. The reported autopsies in recent cases are very few. 1 
They show rupture of the capsule on the inner and lower side, usually 
near the acetabulum and sometimes extending along the neck, and 
laceration of the obturator externus and pectineus. Sometimes the 
obturator is pushed before the head of the bone. In one case (Duboue) 
the femoral vein was torn. The head of the femur rests on the obtu- 
rator foramen or on the ramus beyond it. In a recent one of my own 
the ligamentum teres was untorn ; in another 3 it was torn at its femoral 
insertion, there was a ragged rent in the capsule by the cotyloid notch, and 
slight laceration of the obturator externus and adductor magnus. In a 
case reported by Werner 4 the ascending ramus of the ischium was broken. 
Several specimens of old dislocation have been examined : those of 
Moreau and Stanski, quoted by Malgaigne, Cooper, 5 and SeMillot. 6 

In these the head occupied the 
foramen ovale more or less com- 
pletely, and a new socket had 
been formed by the growth of 
bone around it ; in Cooper's case 
the head was so completely en- 
closed by this new socket that 
it could not be removed from it 
without breaking its edge, and 
yet it was freely movable and 
was covered with articular carti- 
lage. In Stanski's the Y-liga- 
ment had been completely trans- 
formed into bone, and the head 
of the femur lay near the tuber- 
osity of the ischium, the limb 
being much flexed and abducted. 
In Sedillot's the head of the 
femur was atrophied and ir- 
regular, but the limb was so 
serviceable that the patient was 
a professional soldier, and shared 
in all the campaigns of the army. 
Experiments upon the cadaver corroborate the clinical and post- 

1 Treub : Centralblatt fur Chirurgie, 1882, p. 729. 

2 Verhaegke, Gazette des Hopitaux, 1851, p. 283 ; Schinzinger, Wiener med. Presse, 
I860, No. 3, quoted by Poinsot ; Curling, Medical Times and Gazette, 1853, vol. ii. p. 
423 ; Duboue, Bull, de la Societe Anatomique, 1858, p. 496 ; Annandale, British Medical 
Journal, 1870, vol. i. p. 101. 

3 Bolton : Annals of Surgery, October, 1902, p. 586. 

4 Werner: Beitrage zur klin. Chir., vol. xli. 

5 Cooper: Loc. cit., p. 50. 6 Sedillot : Gazette des Hopitaux, 1861, p. 94. 




Obturator dislocation. (Bigelow.) 



THYROID DISLOCATIONS OF THE HIP. 769 

mortem data concerning both the pathology and the mode of produc- 
tion. If the dislocation is produced by abduction of the extended 
limb the rent in the capsule is found to lie on the inner side of the 
joint, while, when it is produced by abduction and outward rotation 
following flexion, or by transformation of a primary dorsal dislocation, 
the rent is mainly on the under side, and its extension in front and 
upward is effected by secondary displacement of the head. The 
Y-ligament, remaining untorn, keeps the limb partly flexed, abducted, 
and everted, the head of the femur rests against the inner and lower side 
of the acetabulum, and is prevented from rising by its pressure against 
this part of the bone and by the untorn portion of the capsule above. 

A case of compound dislocation has been quoted in Chapter LI. 

In a case reported by Cooke * the shaft of the femur was also broken 
just below the trochanters ; the patient was a boy nine years old, and 
the injury was caused by a fall. Probably the dislocation was first 
produced, and then the bone was broken by a continuation of the force, 
or by a second blow. Reduction was easily effected by direct pressure 
on the head, and the patient made a good recovery. 

Symptoms. The limb is flexed, abducted, and usually rotated out- 
ward, and it appears to be elongated because the foot is projected and 
brought to the ground by a compensatory tilting of the pelvis forward 
and downward on the same side (Figs. 345, 346). The trochanteric 
region is flattened, and the trochanter lowered and displaced inward ; 
the adductors are usually tense. The outward rotation of the limb is 
not marked and may be absent, or there may even be some inward 
rotation. 

The statements concerning the comparative length of the limbs on 
measurement are contradictory, presumably because of the failure of 
some observers to place the two limbs in symmetrical positions, or 
because of the greater or less abduction and flexion of the limb when 
measured. Thus, in marked flexion and abduction measurement from 
the anterior superior spine of the ilium to the knee or ankle will show 
shortening of the injured limb; while, if the limb is extended and but 
slightly abducted the measurement may show an actual elongation. 

The head of the femur may be more or less distinctly felt on deep 
pressure toward the obturator foramen from the inner side. The 
statement occasionally made that the head can be felt to move by the 
finger in the rectum pressed against the inside of the foramen when 
the limb is rotated is an error of observation. The same sensation can 
be obtained when the joint is not dislocated, and is due to the alter- 
nate stretching and relaxation of the obturator interims during the 
movement. 

Sometimes the patients have been able to walk quite well immedi- 
ately after the accident, and some of them have not sought advice 
until after the lapse of several days. Sedillot states that this was so in 
three of the five cases which he had seen, and one of the patients came 
to him only because he noticed that he could not completely add net 
the limb. 

The diagnosis of the dislocation and of the variety is made by 
49 * Cooke : Lancet, L864, vol. i. p. ;'>7. 



770 



DISLOCATIONS. 



attention to the attitude and fixation of the limb, the impossibility of 
completely extending and adducting it, the elongation in the extended 
position, the depression of the trochanter, and the presence of the head 
of the femur in its new position. 



Fig. 345. 



Fig. 346. 





Obturator dislocation. (Stimson 



Obturator dislocation. (Johnson.) 



Treatment. Bigelow, in his original paper, gives ten procedures for 
reducing thyroid and downward dislocations, which may be grouped 
as four different methods : 1, manipulation ; 2, traction in the axis of 
the flexed and abducted limb ; 3, traction outward against the upper 
part of the thigh ; 4, transformation into a dorsal dislocation, and 
reduction as such. In his last paper 1 he seems to prefer the last 

1 Bigelow: Lancet, 1878, vol. i. p. 861. 



THYROID DISLOCATIONS OF THE HIP. 



771 



Fig. 347. 



method, adducting the thigh in order to carry the head to the dorsum 
and enlarge the opening in the capsule, and then reducing by flexion 
and forcible lifting of the head toward the socket. 

His directions 1 for reducing by manipulation are : " Flex the limb 
toward a perpendicular, and abduct it a little to disengage the head 
of the bone ; then rotate the shaft strongly inward, adducting it, and 
carrying the knee to the floor. The trochanter is then fixed by the 
Y-ligament and the obturator muscle, which serve as a fulcrum. 
While these are wound up and shortened by rotation (Fig. 347), the 
descending knee pries the head upward 
and outward to the socket. ... In 
this manoeuvre the action of the liga- 
ment may be aided, if necessary, by a 
towel passed round the head of the 
femur to draw it upward and outward. 
Rotation outward may be substituted 
for inward rotation." 

The clinical histories show that in- 
ward and outward rotation have suc- 
ceeded, each after the other has failed, 
and that the former is quite likely to 
transform the dislocation into a posterior 
one ; as outward rotation most surely 
prevents this change, surgeons appear 
now to prefer it. The directions given 
by Kocher, 2 and approvingly quoted by 
the German surgeons, are as follows : 

1. Flexion of the thigh to a right angle with the pelvis, while 
preserving the abduction and outward rotation in which the limb is 
found. This leaves all parts of the capsule relaxed. 

2. Traction, to make the posterior part of the capsule tense, and to 
bring the head nearer the socket. 

3. Outward rotation, which, acting through the tense posterior por- 
tion of the capsule and outer branch of the Y-ligament, brings the 
head upward and backward into place. 

Direct pressure or traction outward upon the upper part of the thigh 
has often proved a valuable aid, either by directly moving the head of 
the femur toward the socket or by furnishing a fulcrum by means of 
which the head could be moved in this direction by adducting the 
knee. One of Bigelow's procedures, for example, is to place the 
patient " in a sitting posture with a log, or post, or bedpost between 
his thighs, and pry the head outward over this fulcrum by means of 
the long shaft of the femur." 

My own cases have been easily reduced, under ether, by increasing 
the flexion and rotation, making traction in the long axis of the limb, 
and then lowering and rotating inward or back and forth. 

Kocher 3 reduced a dislocation of four weeks' standing, which had 
resisted all other methods, by making continuous traction in the axis 




Reduction of obturator dislocation by 
rotation ; showing the mechanism of the 
manoeuvre. (Bigelow.) 



> Bigelow : The Hip, p. 79. 
:i Kocher : Loc. oit., p. 620. 



'-'Kocher: Volkmann's klin. Vortriige, No. S3. 



772 



DISLOCATIONS. 



of the limb and combining with it elastic traction laterally on the 
upper part of the thigh. On the morning of the fourth day reduction 
was found quietly to have taken place. 

In a case in which the dislocation had existed for twenty months 
and the disability was great, MacCormac excised the head and tro- 
chanter with a good result. The patient was a sailor nineteen years 
old. For details of the case (see Chapter LIIL). 

Perineal Dislocations. 

The recorded cases of this form are not numerous. 1 It is character- 
ized by the presence of the head more superficially placed than in the 
obturator variety and displaced to a greater distance from the socket, 
so as even in one case to press upon the urethra and interfere with the 

Fig. 348. 




Perineal dislocation of hip. (Stimson.) 



voiding of the urine. In Taylor's case, quoted above among compound 
dislocations of the hip, page 745, the dislocation was made compound 
by a rent in the integument of the perineum nearly two inches long ; 
and, possibly, Woodward's case, quoted in the same section, may be 
looked upon as an extreme form of this variety. 

The cause appears to be extreme abduction of the limb, caused in 
my three cases by the fall of a heavy body upon the patient's back as 
he stood or knelt with the thigh flexed and abducted. Probably the 

1 See also a paper by Kiedenger in Munch, med. Wochenschrift, August 16, 1892. 



SUPRAPUBIC DISLOCATIONS OF THE HIP: 7 IS 

capsule is widely torn, and thus may be explained the varying attitude 
of the limb in respect of inversion or eversion. In an autopsy reported 
by Shaw 1 not only was the capsule extensively detached at its inner 
and posterior insertion upon the acetabulum, but also the iliofemoral 
ligament was partly separated from the neck of the femur, and a small 
rent extended from that point into the capsule. 

In my three cases 2 the thigh was flexed and abducted so that it stood 
far out from the side of the body, making an angle of between 60 and 
70 degrees with the sagittal and frontal planes (Fig. 348). When the 
other limb was placed as nearly as possible in the corresponding posi- 
tion (the same degree of abduction could not be obtained) the distance 
between the knees was thirty inches, and measurement from the ante- 
rior superior spine to the knee showed from one and a half to four 
centimetres shortening. A rounded mass, the head of the femur, 
could be felt beginning one inch from the mid-line of the perineum 
and extending forward to the adductor longus and backward nearly to 
the level of the anus. Adduction and extension painful and opposed ; 
slight additional flexion and rotation possible. All were easily reduced 
by the method given above, flexion and traction. 

Theoretically reduction should be most readily effected by traction 
in the axis of the abducted limb and by direct pressure upon the head 
of the bone or upon the upper part of the shaft, anaesthesia being used 
to prevent opposition by the muscles. The extensive laceration of 
the capsule and ligaments would probably make purely manipulative 
methods ineffective. 

DISLOCATIONS UPWARD AND FORWARD, AND INWARD AND 
FORWARD. SUPRAPUBIC. 

Iliopectineal. Pubic. Intrapelvic. 

In these dislocations the head of the femur comes to rest upon the 
superior ramus of the pubis, either at the iliopectineal eminence above 
and a little to the inner side of its normal position (iliopectineal), or, 
more rarely, nearer the symphysis pubis (pubic). On the one side the 
position merges into that of the supracotyloid, and on the other into 
that of the obturator. Some of the iliopectineal, in which the head has 
remained very close to the anterior inferior spine of the ilium, have been 
described by their reporters and others under the name supracotyloid, 
and some writers describe the pubic variety as a variety of the obtu- 
rator, or, rather, of a class to which they give the name prceglenoid or 
dislocations forward and inward. Exceptionally the head may pass 
under or through Poupart's ligament and rest in the iliac fossa, the 
intrapelvic or suprapectineal dislocations. 

The head of the bone may leave the socket at its upper and inner 
part, and in this case it appears probable that the head rests on the 
iliopectineal eminence, or it may leave it at a somewhat lower point 

1 Shaw: Transactions of the Pathological Society of London. 1859, vol. x. p. 211. 

2 For full details of two see New York Medical Journal, August 3, 1889; the third is 
shown in Fig. 348. 



774 DISLOCATIONS. 

and pass inward and forward to the symphysis, or it may pass at first 
inward and downward across the obturator foramen while the limb is 
flexed, and then move upward to rest upon the upper and front surface 
of the superior ramus of the pubis as the limb is subsequently low- 
ered. It is to be remembered that the upper border of the symphysis 
pubis is a little below the level of the centre of the cotyloid cavity in 
the upright position. 

In correspondence with these differences in the position taken by the 
head are found differences in the mode of production, according as the 
head is moved more directly upward, upon the iliopectineal eminence, 
by hyperextension of the limb, or is first turned more directly forward 
by outward rotation and abduction and then, after rupture of the ante- 
rior and inner part of the capsule, is pressed upward or inward. Of 
the former there are a number of clinical examples in which the limb 
itself has been hyperextended, or, more commonly, the trunk has been 
violently pressed backward while the limb was fixed ; thus, a man steps 
into a hole and falls backward ; another, wrestling, is forcibly bent 
backward by his antagonist. Of the latter, outward rotation and 
abduction, the clinical instances are not so clear, but the possibility of 
the production in this manner has been fully proved by experiment 
upon the cadaver ; a muscular woman, 1 carrying a keg of potatoes on 
her back, stumbled and, to avoid a fall forward, threw her body with 
a twisting movement backward ; a man 2 while swimming made a vigor- 
ous thrust with his legs and felt a sharp pain in the groin ; he was still 
able to walk, though with much difficulty, and on examination a dislo- 
cation upon the pubis was found. 

Pathology. The pathology has been shown by several autopsies in 
recent and old cases. Aubry 3 found the capsule torn along its anterior 
half near its insertion upon the acetabulum ; the psoas and the crural 
nerve crossed the front of the neck ; the head of the femur lay between 
the psoas and pectin eus, raising the latter and the vessels ; there was 
an interval of two centimetres between it and the anterior inferior 
spinous process of the ilium. Roser 4 found the rent in the front of the 
capsule extending from the anterior inferior spinous process down to 
the notch ; the psoas and iliacus were pushed outward, and the vessels 
crossed the head ; the small external rotators were drawn inward and 
pressed into the acetabulum by the great trochanter. Albert (loc. cit., 
p. 276) found the head resting against the outer side of the'iliopectineal 
eminence and covered on its inner half by the psoas and iliacus ; when 
it was pressed further upward the muscle lay across its neck. The 
iliopectineal fascia (the deeper part of the sheath of the vessels) was 
untorn, but nevertheless the artery was displaced outward by the head 
so that it rested across its centre and curved outward immediately 
below Poupart's ligament ; the capsule was torn above and in front 
for about one-third of its circumference, the greater part of the ilio- 
femoral ligament being uninjured; the ligamentum teres was torn 
away at its insertion upon the head, and the cartilaginous rim of the 
acetabulum was entirely uninjured ; the posterior rotators were relaxed 

1 Albert : Chirurgie, vol. iv. p. 274. 2 "Ore : Lancet, 1857, vol. ii. p. 470. 

3 Aubry : Bull, de la Societe de Cbirurgie, 1S53, vol. iii. p. 377. 

4 Eoser: Arch, fur pbys. Heilkunde, 1857, vol. i. p. 58. 



SUPRAPUBIC DISLOCATIONS OF THE HIP. 775 

Kocher l found the capsule torn along its anterior half close to its inser- 
tion upon the femur, the portion which remained attached to the acetab- 
ulum hanging as a flap between the head and the socket ; the psoas and 
iliacus were stretched across the neck of the bone, and the vessels lay 
to the inner side of the head ; the liga men turn teres was torn away 
near its attachment to the acetabulum, and the cartilaginous rim of the 
socket was uninjured. 

Borchard 2 reports a case with avulsion of the great trochanter and 
a hernia beneath the detached Poupart's ligament, and cites a similar 
case reported by Lauenstein. 

In a case reported by Stokes 3 in which the head had passed over the 
brim into the pelvis, the superior ramus of the pubis had been frac- 
tured and much comminuted. The patient died on the table immedi- 
ately after reduction, by pulmonary embolus, it was thought. 

Cases in which the dislocation was compound have been quoted in 
Chapter LI., p. 745 ; in one of them the femoral vein was ruptured. 
In a case reported by Goldsmith and quoted on p. 440, in which 
the dislocation had remained unreduced for two months when the 
patient came under observation, there was found a diffused pulsating 
swelling occupying the iliac fossa and extending down to the middle 
of the thigh, which had appeared a few days after the accident ; the 
external iliac artery was tied, and at the patient's death, five days 
later, the femoral and external iliac arteries were found to be perforated 
for the distance of an inch on their postero-external aspect, and the 
head of the femur lying in the cavity of the aneurism. 

Fig. 349. 




Old unreduced suprapubic dislocation of the hip. (Cooper.) 

In one or two cases pressure upon the anterior crural nerve has been 
manifested by numbness in its area of distribution. 

1 Kocher : Loc. cit., p. 61(>. '-' Borchard : Deutsche Zeitschrift fur Chir., vol. Ixvi. p. 572, 
3 Stokes: British Medical Journal, 1880, vol. ii. p. 916. 



776 



DISLOCATIONS. 



Fig. 350. 



A case treated by Brausby Cooper l and examined after death at the 
end of three weeks is reported in detail, but it is not clear how much 
of the laceration of the muscles was due to the dislocation and how 
much to the repeated attempts to reduce it. " The anterior part [of 
the capsule], where crossed by the tendons of the psoas and iliacus 
muscles," was the only part untorn ; the head of the femur lay in the 
groin on the inner side of the great vessels and above the internal 
circumflex artery. 

In an old case examined by Sir Astley Cooper * " the head of the 
thigh bone had torn up Poupart's ligament, so as to penetrate be- 
tween it and the pubes. . . . Upon the pubes a new acetabulum is 
formed for the neck of the thigh bone, the 
head of the bone being above the level of the 
the pubes (Fig. 349). . . . The femoral artery 
and vein were placed on its inner side, 
so that the head of the bone rested between the 
crural sheath and the anterior inferior spinous 
process of the ilium." 

Yerneuil, 2 in attempting to make reduction 
thirty-six hours after the accident in a patient 
eighty-one years old, fractured the neck of 
the femur. Four years later the patient died ; 
the head was found lying in the notch between 
the anterior inferior spinous process and the 
iliopectineal eminence, between the psoas and 
the rectus. In another old case reported by 
Douglas 3 in which there was also a fracture of 
the neck of the femur the head was on the 
inner side of the vessels; the history of the case 
did not show when the fracture had been pro- 
duced. 

Symptoms. The cases in which the head of 
the femur lies upon the iliopectineal eminence 
appear to be the more common, and this may, 
therefore, be taken as the typical form ; in it 
the limb is but slightly, if at all, abducted, 
markedly everted, and somewhat shortened 
(Fig. 350), and the head of the femur can be 
felt more or less distinctly in the groin, with 
the artery pulsating directly in front of it or to its inner side. When 
the head is displaced further toward the median line the limb is 
abducted and flexed as well as everted, and its position is more like 
that of an obturator dislocation ; the capital difference is the position 
of the head on the pubis where it can be distinctly felt and perhaps 
even seen. The vessels lie on its outer side. In both forms the outer 
and posterior portions of the hip are flattened, and the trochanter can 
be felt covering the cavity of the acetabulum. 




Iliopectineal dislocation. 
" The limb is usually a little 
more advanced and abduct- 
ed." (Bigelow.) 



1 Cooper : Loc. cit., p. 78, and Guy's Hospital Eeports, 1836, vol. i. p. 82. 

2 Cooper: Loc. cit., p. 71. 

3 Yerneuil: Bull, de la Societe de Chirurgie, 1870, vol. xi. p. 115. 

4 Douglas: London and Edinb. Monthly Journ. of Med. Sci., 1843, vol. iii. p. 



1064. 



SUPRAPUBIC DISLOCATIONS OF THE HIP. 777 

Adduction is difficult or impossible ; abduction and flexion usually 
are easy. Some patients have been able to walk immediately after 
the accident, but none appear to have done so as freely as some with 
obturator or supposed supracotyloid dislocations. 

The attitude of the limb is like that found after fracture of the 
neck of the femur, and the differential diagnosis is made by attention 
to the presence of the head in the groin, the flattening of the outer 
aspect of the hip, and the depression of the trochanter. 

In a case reported by Rothe l the patient, a girl fifteen years old, 
was unable to extend the leg upon the thigh three weeks after the acci- 
dent, and the disability was attributed to overflexion of the knee at the 
time the dislocation was received. While pushing a swing forward 
she tripped, fell on her knee, and was then pressed backward to the 
ground by the returning swing. Reduction was made under chloro- 
form by flexion, rotation inward, and adduction. 

Of the intrapelvic (Scriba) or suprapectineal (Bartels) dislocation 
cases have been reported in detail by Scriba, 2 Bartels, 3 and Stokes 
(above quoted). Scriba's patient, a boy thirteen years old, w T hile stand- 
ing with his legs wide apart and the left one thrown back, was struck 
upon the breast and overthrown. The limb was flexed at the knee and 
hip, adducted and rotated inward. The head of the femur lay above 
the torn Poupart's ligament deep in the iliac fossa, and the neck rested 
on the superior ramus of the pubis. The artery, vein, and nerve 
crossed the head and were fully compressed. Slight inward rotation 
and adduction were the only movements possible. During manipula- 
tion outward rotation suddenly took place and persisted. Reduction 
was made by lifting the head with the fingers until it rested on the 
ramus, and then following with acute flexion, adduction, inward rota- 
tion, and finally extension. 

Bartels' s patient was a man forty-seven years old who had been 
thrown down by a heavy weight. The limb was shortened about three 
inches, fully extended, parallel to the median line of the body, and 
widely rotated outward. The fold of the groin was obliterated by a 
diffuse swelling extending to the upper limit of the left hypogastrium ; 
the head could be distinctly palpated through the abdominal wall, 
which it slightly raised ; the greater trochanter was directed backward 
and could not be felt. Flexion was impossible ; inward rotation very 
limited. 

Treatment. The rule, of which the application is so general, that in 
attempting reduction the limb should first be placed in the position 
which it occupied when the dislocation occurred, is not suitable to 
those suprapubic dislocations in which the dislocation takes place 
while the limb is extended. Traction upon the fully extended, 
abducted, and everted limb has indeed been sometimes successful, but 
it has oftener failed and has led to various accidents. The method 
was early abandoned because of the risk of injury to the vessels by 
overstretching across the projecting head of the femur, and flexion was 

1 Rothe : Deutsche Klinik, 1868, p. 343. 

2 Scriba: Centralblatt fur Chirurgie, 1S79, p. 703. 

3 Bartels: Arch, fiir klin. Chir., vol. xvi. p. 651. 



778 DISLOCATIONS. 

resorted to to diminish this risk and to remove what was thought to be 
the principal obstacle, tension of the psoas and iliacns. Of the six 
procedures given by Bigelow almost all include traction upon the 
flexed thigh and rotation inward ; in some, direct pressure downward 
and outward upon the head of the bone or the upper part of the thigh 
is recommended, and outward rotation is mentioned in one as an equally 
good substitute for inward rotation. 

Kocher's method is the same as one of those given by Bigelow, and 
I reproduce it here because of its more detailed account of the obstacles 
to be overcome and the means by which the manipulation accom- 
plishes it. 

Flexion relaxes the Y-ligament, but nevertheless by tightening the 
posterior part of the capsule it presses the head more firmly against 
the brim of the pelvis or even pushes it further upward under Pou- 
part's ligament ; it is therefore necessary that the movement should 
not be allowed to take place upon the head as a centre, but that the 
head should be enabled or forced to descend along the anterior surface 
of the pelvis as the knee is raised before the tightening of the posterior 
portion of the capsule has made this descent impossible. This can be 
effected by traction in the axis of the limb or by direct pressure down- 
ward and backward upon the head. The steps of the method, then, 
are : 

1. Traction in the axis of the limb as it lies, in order to bring the 
head below the brim of the pelvis ; it is rarely necessary to aid this by 
increasing the extension, abduction, and outward rotation of the limb. 
By this means the posterior portion of the capsule is made tense, and 
its point of attachment to the back of the neck of the femur is thereby 
made the centre for the following movements : 

2. Pressure with the hand upon the head of the femur to prevent its 
return upward during flexion. Sometimes this is sufficient to make 
reduction. 

3. Flexion, in order to relax the Y-ligament ; it should not be car- 
ried to a right angle, otherwise too much strain will be made upon the 
posterior portion of the capsule. 

4. Potation inward, by which the head is returned to the socket. 
In cases in which the head lies nearer the symphysis abduction of 

the limb during traction is necessary to relax the Y-ligament and the 
untorn portion of the capsule and thus allow the head to approach the 
acetabulum ; and in those, possibly rare, cases in which this position is 
secondary to a primary displacement downward and inward (obturator) 
the flexion will be seen to bring the head back to the obturator fora- 
men, and then the final steps should be those suitable to that form of 
dislocation. 

DISLOCATIONS DIRECTLY UPWARD. 

Subspinous (Bigelow). Supracotyloidea. Sus-cotyloidienne 

(Malgaigne). 

Concerning no other class of reported cases of dislocations of the hip 
is the uncertainty as to the nature and extent of the lesion, the point 



DISLOCATIONS OF THE HIP. 770 

at which the head has left the socket, and the mode of production so 
great as in those in which the head is found more or less directly above 
the socket. As has been above said, Blasius grouped under one head 
— supracotyloidea — cases in which the head of the femur comes to rest 
above the socket either by secondary displacement forward and upward 
from a primary dorsal (the everted dorsal of the present classification), 
or by secondary displacement backward from a primary suprapubic, or 
by direct dislocation upward, and this grouping, which, while very 
proper in a monograph, seems to me objectionable in a systematic 
description of all the forms, has been accepted and followed by several 
of the later German writers, Albert, Konig, Lossen. Bigelow groups 
Malgaigne's variety with those cases in which the head lies further to 
the inner side (suprapubic), and makes them all a subvariety under 
the name subspinous. Hamilton makes no formal classification of 
them, but contents himself with citing a few cases, mainly as "anom- 
alous dislocations, " some as subspinous, others as supraspinous. 

The essential feature of the class, as I view it, is the rupture or 
avulsion of the upper part of the Y-ligament ; this differentiates it 
radically in its probable mode of production and treatment from those 
in which the head of the bone comes to rest at or near the same place 
after having left the socket at a lower point in front or behind and 
passed upward on either side of the untorn ligament. 

The incompleteness of many of the descriptions is such that the 
material for a positive opinion upon the character of the displacement 
is lacking, and such cases must, therefore, be passed by without defi- 
nite classification, but there remain a few which sufficiently establish 
the existence of this variety in which the head is displaced directly 
upward toward or a little behind the anterior inferior spinous process 
of the ilium. 

The cases in which the position of the head of the femur has been 
verified by autopsy are those of Wormald, 1 Gerdy, 2 Travers, 3 and St. 
George's Hospital/ and the doubtful ones of Cruveilhier, 5 Gely, 6 and 
Deville. 7 WormakPs patient was a man forty years old, avIio had 
received his injury at the age of fourteen, and had since had good use 
of the limb. The head of the femur lay " between the edge of the 
acetabulum and the anterior inferior spinous process," and was sur- 
rounded by the capsule. The ligamentum teres was not ruptured. The 
cotyloid cavity formed part of the new socket. The limb was some- 
what everted and abducted, and shortened half an inch. Gerdy's patient 
was caught in a revolving shaft and whirled around by it many times. 
He died on the following day. The head of the femur lay on the 
outer third of the upper border of the acetabulum, below and just out- 
side of the anterior inferior spinous process ; the capsule was torn along 
the upper edge of the cavity, and the centre of the head was eight lines 

1 Wormald: London Medical Gazette, 1837, vol. xix. p. 658. 

2 Gerdy : Reported by Baron, Gaz. Medicale de Paris. 1838, p. 630. 

3 Travers: Medieo-Cbirnrgical Transactions, 1837, vol. xx. p. 112. Autopsy by Cadge : 
Ibid., 1855, vol. xxxviii. p. 88. 

4 St. George's Hospital : Lancet, 1840-41, vol. ii. p. 281, 

5 Cruveilhier: Bull, de la Soc. Anatomique, 1837, p. 104. 

6 Gely : Ibid., 1840, p. 303. 7 Deville : Ibid., 1843. p. -Jo I. 



'80 



DISLOCATIONS. 



above that of the latter. Fig. 260 represents an apparently similar 



specimen. 
In Travers 



and Cadge' s 



Fig. 351. 




case the head lay between the superior 
and inferior spinous processes of 
the ilium (Fig. 351) and was' cov- 
ered by a complete bony cap lined 
with a dense pearly-white tissue 
resembling fibro - cartilage. The 
edge of the new cavity was con- 
nected with the neck of the femur 
by a thick capsular ligament. 
The rectus muscle, which had 
been torn from its origin, was in- 
serted upon the edge of the new 



cavity. 
The 
was a 
femur 
to the 



St. George's Hospital case 
recent one ; the head of the 
lay about an inch below and 

outer side of the anterior 



Old supracotyloid dislocation 
and Cadge's case. 



Travers's 



spinous process, and the trochanter 
was still further to the outer side and 
behind ; the trochanter minor rested 
on the outer edge of the acetabulum. 
The capsular ligament was exten- 
sively lacerated at its upper part. 
The gluteus medius and minimus 
were nearly torn through about two 
inches from their attachment to the trochanter ; the gemelli and quad- 
ratic femoris were slightly lacerated. 

The following case, which I reported in the Annals of Surgery, De- 
cember, 1892, shows the symptoms (Fig. 352). A man forty years old 
was thrown down by a heavy case which slipped while he was unload- 
ing it from a wagon and forced him backward against another box and 
then sidewise to the ground. When I saw him, three hours later, he 
was lying on his back with the right thigh extended, slightly abducted, 
and so far everted that the foot rested along the entire length of its 
outer border on the bed. The upper anterior portion of the thigh close 
below the groin was rounded and swollen, and showed two incomplete 
transverse rents in the skin about two inches long and about two inches 
below the anterior superior spine of the ilium, which evidently had 
been caused by overstretching of the skin (hyperextension of the 
joint). The outward rotation gave the thigh a very peculiar appear- 
ance ; the bulk of the quadriceps extensor formed a longitudinal mass 
on the outer side between the anterior (inner) aspect and a deep longi- 
tudinal depression extending from the trochanter to the side of the 
knee. Every attempt to move the limb caused pain and sharp con- 
traction of the muscles. 

Ether was administered. The limb could then be easily placed 



DISLOCATIONS OF THE III P. 



78 J 



alongside of and parallel with the other ; the shortening was two cen- 
timetres. The head of the femnr lay directly beneath the skin and 
could be distinctly outlined. It lay just external to a line drawn 
downward from the anterior superior spinous process, and its upper 
border was about one inch below that prominence. Internal rotation 
was impossible ; moderate flexion was easy. 

Keduction was easily effected by flexing the hip about twenty 
degrees, and then making moderate traction along its axis with one 
hand at the knee, and direct pressure downward and backward upon 
the head of the femur with the other. By fully extending the thigh 
and making slight pressure forward against the upper part of its pos- 
terior aspect the dislocation was easily reproduced, and was then again 
reduced as before. 

Fig. 352. 




Upward dislocation of the hip. (From a photograph.) 



Tli rough what was apparently an extensive gap in the soft parts 
beneath the skin at the point occupied by the head of the femur before 
reduction I could distinctly feel the surface of the ilium and, a little 
in front, the anterior inferior spinous process. 

A long side splint was applied, and the patient placed in bed. 

Convalescence was uneventful, and the patient was discharged, April 
15th, thirty-six days after the accident. May 24th he called on me : 
he walked without a cane, and complained only of a slight feeling of 
weakness in the limb. Superextension of the hip caused no pain: 
active flexion of the hip was restricted one-half. 

I know of no case exactly like it. One reported by Morgan 1 resem- 
bles it in the apparent mode of production and the attitude of the 

1 Morgan : Guy's Hospital Reports, 1836, p. 79, 



782 DISLOCATIONS. 

limb, but the head of the bone lay below and to the inner side of the 
anterior superior spine. Possibly Cheever's case, quoted in Chapter 
LI. among compound dislocations, may have been of the same kind ; 
the description is not sufficiently detailed to make it certain, It was 
evident that my case just escaped being made compound by rupture 
of the tense skin. In Mason's and Allin's 1 and in Tiffany's, 2 the 
attitude was similar and the head of the bone could be felt below or 
below and to the inner side of the anterior superior spine. Allin 
reported his case as a suprapubic dislocation; his patient received the 
injury by stumbling and falling forward while ascending a flight of 
steps. In each case reduction was effected with some difficulty by 
traction and, in Allin's and Tiffany's, rotation inward. Possibly some 
of the " intrapelvic " dislocations have been produced in the sam<3 
manner, and differ only in the higher position of the head given by 
secondary displacement. 

There is another small group of cases in which the displacement is 
thought to be of thu same kind but of less extent, and the opinion 
finds some support in the autopsy of Wormald's case, above quoted. 
There are eversion, slight shortening, and some flexion of the limb, 
and the patients have usually been able to walk. The head of the 
femur cannot be felt ; the trochanter is prominent, slightly elevated, and 
more distant from the symphysis pubis than its fellow is. Milner's 3 
case is the least doubtful example. It may be remembered that cases 
with quite similar symptoms have been reported as thyroid disloca- 
tions. 

In others, with the same attitude of the limb, the head of the femur 
could be felt directly above the socket or a little to the inner side. 

In the first group it is evident that in some the Y-ligament and 
attachment of the rectus are freely ruptured, and that in others the 
head is displaced slightly upward and the upper part of the capsule 
only partly torn, and the neck of the femur probably crossed by the 
untorn rectus, a condition differing only slightly from the suprapubic. 

In the second group it is possible that the head is displaced upward 
to the outer side of the inferior spinous process where it would be 
hidden by the overlying muscles, but in that case the marked eversion 
noted in all is inexplicable without rupture of the Y-ligament. I am 
disposed to think the cases were all thyroid dislocations, an opinion 
supported by the slight fulness of the groin and elevation of the fem- 
oral artery noted in Milner's. 

DISLOCATION DOWNWARD UPON THE TUBEROSITY OF THE 
ISCHIUM. INFRACOTYLOID. 

In this form of dislocation the head escapes over the lower edge of 
the socket and rests just below it upon the outer surface of the body 
of the ischium. The reported cases are very few, 4 but it seems prob- 

1 Allin : Eeported by Hamilton, loc. cit., p. 785. 

2 Tiffany : Maryland Medical Journal, 1883, vol. x. p. 525. 

3 Milner : St. Bartholomew's Hospital Eeports, 1874, vol. x. p. 316. 

* For bibliography and cases see : Chapplain, Bull, de la Soc. de Chir. , 1874, p. 461 ; Wen- 
del, Deutsche Zeitschrift fiir Chir., 1904, vol. lxxii. p. 153, and Nie^erle. Ontralblatt fur 
Chir., 1905, p. 31 (20 cases). 



DISLOCATIONS OF THE HIP. 783 

able that the dislocation is much more frequent as a primary, transi- 
tory one, leading to either a dorsal or an obturator dislocation, being 
converted into the former by inward rotation and adduction, or into 
the latter by outward rotation and abduction ; and, furthermore, some 
of the cases have probably been reported as obturator dislocations, for 
the dividing line between them is somewhat arbitrary ; thus, Keate's 
case, referred to above in the paragraph on the causes of obturator 
dislocations, is quoted by Malgaigne as a subcotyloid dislocation. The 
form was first described by Bonn l in 1800, and again by Ollivier. 2 

The cause is the same as that of many dorsal and obturator disloca- 
tions, namely, forcible flexion of the thigh, but exaggerated abduction 
followed by slighter flexion appears also to be capable of producing it. 
Thus, in a case reported by Roux 3 the patient fell with his right leg in 
a hole ; the left one remained stretched out on the ground in abduction 
and was dislocated ; and Ollivier' s patient, a man, seventy-two years 
old, was knocked down by a branch of a falling tree which struck 
against the lower inner part of his right thigh and forcibly abducted it. 
Pitha 4 speaks of a case in which the dislocation was caused by the 
forcible bending of the body backward, but, as Albert points out, not 
only is his description of the symptoms unintelligible, but it also does 
not appear how a rent in the lower part of the capsule could be pro- 
duced in this way. He describes the supracotyloid and infracotyloid 
together as " vertical dislocations," and possibly has placed this case 
in the wrong paragraph. 

The only autopsy is one reported by Luke, 5 the patient, a man, fifty 
years old, died in consequence of associated injuries ; the dislocation, 
which had been easily reduced, was reproduced at the autopsy, and as 
the bone could be made to take no other position it was thought that 
the reproduction was exact. The head of the femur was situated 
" midway between the ischial notch and the thyroid hole, immediately 
beneath the lower border of the acetabulum ; " the gemellus inferior 
and quadratus femoris had been torn, and the ligamentum teres com- 
pletely detached ; the capsule was torn in its lower part. 

Experiment upon the cadaver shows that the Y-ligament remains 
untorn and compels flexion of the thigh upon the pelvis, which, how- 
ever, may be masked, as in other forms, by inclination of the pelvis. 
The retention of the head upon the tuberosity is due to the narrowness 
of the rent in the capsule and to the support given by the untorn por- 
tions; and as the laceration can be easily extended on either side the 
easy transformation into a dorsal or obturator dislocation is intelligible. 

The flexion may be even to a right angle ; Ollivier's patient was 
brought to the hospital seated in a chair ; the limb is more or less 
abducted, and may be slightly inverted or everted. Measurement in 
Ollivier's case, when the other thigh was brought into a similar posi- 
tion, showed no difference in length, and by the lengthening which has 
been noted in other cases was probably meant only an apparent elon- 

1 Bonn : Quoted by Lessen. 

2 Ollivier: Arch. gen. de Med., 1 8:23, vol. i i i . p. ,")(\">. 

3 Roux: Revue M6dico-chirurgicale, 1849, vol. v. p. 364. 

4 Pitha: Pitha and Billroth, p. l(j;i. 

5 Luke: Medical Times and Gazette, 1858, vol. i. p. 12. 



784 DISLOCATIONS. 

gation due to the abduction and the consequent inclination of the pelvis. 
The buttock appears rounded and more prominent, especially when 
looked at from below when the patient is lying on his back with both 
thighs flexed, and the adductors of the thigh are tense and prominent. 
The great trochanter is further from the crest of the ilium, and, the 
head of the femur can sometimes, but rarely, be felt in its new position. 

Movements of the limb are restricted and more or less painful ; 
flexion to a right angle is usually possible, abduction comparatively 
free, adduction limited ; but in Roux's case the thigh could be carried 
across the other one. Both of Gurney's l patients could walk fairly 
well immediately after the accident, and Roux's could walk a little at 
first, but was soon completely disabled by the pain. 

Reduction has been easy (Roux was unsuccessful on the thirty-fifth 
day with the aid of chloroform) and has usually been effected by trac- 
tion in the axis of the limb, with or without direct pressure upon the 
head of the bone ; sometimes the dislocation has been first transformed 
into a dorsal or obturator and then reduced. 

A suitable method would be : Flexion, if not already present ; trac- 
tion ; correction of the existing rotation, if any ; to be aided by direct 
pressure on the head of the femur from behind. 

Dislocation into the pelvis through the fractured floor of the acetab- 
ulum has been described in Chapter XXII. A brief reference is 
made by Kronlein 2 to a unique case observed by him in which, by a 
fall upon the feet, the head of each femur was driven through the floor 
of the acetabulum. 

1 Gurney : Lancet, 1845, vol. iii. p. 412. 

3 Kronlein : Deutsche Chirurgie, Lief. 26, p. 25, 



CHAPTER LIII. 

DISLOCATIONS OF THE HIP.— (Continued.) 

Complications — Simultaneous Dislocation of Both Hips — Accidents in Attempts 
to Reduce — Prognosis — Habitual Dislocations — Treatment of Old Disloca- 
tions — Congenital and Pathological Dislocations. 

COMPLICATIONS OF DISLOCATIONS OF THE HIP. 

Among the complications of dislocations of the hip are unusually 
extensive injuries to the soft parts, rupture of or dangerous pressure 
upon large nerves and blood-vessels, and fracture of bones. Mention 
has been made of all in connection with the different varieties of 
dislocation, and it is necessary only to group and briefly summarize 
them. 

Rupture or laceration of the muscles about the joint is doubtless 
present in some degree in all cases, and is rarely so extensive as to 
deserve to be looked upon as a complication. In the dorsal disloca- 
tions the head of the femur may be so far displaced that the gluteus 
medius, and even the gluteus maximus may be in part ruptured, and 
in the thyroid dislocations the adductors may be extensively torn from 
the inferior ramus of the pubis and the adjoining part of the ischium, 
as observed in Taylor's compound case above quoted. In the supra- 
pubic form the pectineus may be torn, and in the extreme variety 
known as " intrapelvic," in which Poupart's ligament is ruptured, the 
attached muscles forming the anterior wall of the abdomen must also 
suffer some injury. ,The extension of the bruising and laceration of 
course increases the shock and inflammatory reaction, but calls for no 
special treatment beyond a more rigid and prolonged confinement to 
bed and avoidance of movement. 

For compound dislocations see Chapter LI. 

Rupture or injury of the femoral vessels has been observed only in 
suprapubic and obturator dislocations. The suprapubic ones are those 
of a German military surgeon 1 and Goldsmith, 2 quoted in Chapters 
XXIX. and LI. ; the obturator case is that of Duboue. 3 In the first 
mentioned the femoral vein was torn and the patient died promptly ; 
in Goldsmith's an aneurism involving the external iliac and femoral 
arteries formed, and was treated two months after the accident by liga- 
ture of the external iliac ; the patient died. In Duboue's case there 
was also fracture of the pelvis at the junction of the ilium and pubis, 
but without displacement ; the head of the femur rested upon the 
ischio-pubic branch of the pelvis rather below than upon the obturator 
externus ; the femoral vein was torn. The patient died. 

1 Centralblatt fur Chirurgie, 1880, p. 504. 

2 Goldsmith: American journal of the Medical Sciences. July, I860, p. 30. 

3 Duhoue : Bull, de la Soc. Anatomique, 1858, p. 49(>. 

50 785 



786 DISLOCATIONS. 

The sciatic nerve in the autopsy of one dorsal dislocation 1 has been 
found stretched across the front of the neck of the femur, and in sev- 
eral dislocations produced experimentally upon the cadaver it has been 
found in the same position, but the only recorded instances within my 
knowledge in which symptoms of injury to it have been present'are a 
case reported by Jonathan Hutchinson 2 in which the muscles supplied 
by it were paralyzed and remained so at the time of the report several 
months after the accident, and one by Allis (The Hip) in which the 
attempts to reduce were thought to have wound the nerve about the 
neck of the femur. 

Associated fractures of the head, neck, and shaft of the femur, of 
the rim and floor of the acetabulum, and of different parts of the 
pelvis have been reported. 

Fracture of the head of the femur has been reported in four cases of 
dorsal dislocation. 3 

Fracture of the neck of the femur occurring coincidently with the 
dislocation or subsequently during an attempt to reduce has been 
observed a number of times. Wippermann 4 reported one case and 
collected thirteen others of which he gives abstracts, but his list 
includes one case (Hervez de Chegoire) which was probably a simple 
fracture without dislocation, and Birkett's, in which the fracture was 
of the head, and does not include a number of other reported cases; 
thus, Hamilton quotes no less than twelve cases in which fracture was 
caused during an attempt to reduce, and of these Wippermann's paper 
contains only one. The only cases of which I have knowledge 5 in 
which the neck appears certainly to have been broken at the moment 
of dislocation are one reported by Tunnecliff, 6 one by Post 7 in which 
both hips were dislocated, and one by Lossen, 8 and even in the latter 
the patient was not seen by the reporter until six weeks after the acci- 
dent ; the patient, an old man, was standing on a ladder when it fell, 
he struck upon his feet and then, with the injured side, against the 
underlying ladder, and Lossen supposed the dislocation to have been 
produced by the second blow. " The head lay on the ilium ; the limb, 
almost consolidated, still showed signs of extracapsular fracture." 

When Dr. Tunnecliff saw his patient a month after the accident he 
was inclined to doubt the existence of a fracture, but he felt forced to 
accept the evidence as conclusive. He found " the same shortening 
and oblique position of the limb as described above." On the thirty- 
eighth day after the accident reduction was effected by free manipula- 
tion to break up the adhesions, followed by flexion and abduction with 
direct pressure on the head ; the bone returned to the socket with an 
audible snap, but as crepitus was felt it was thought that the union of 

1 Quain : Medico-Chirurgical Transactions, 1848, vol. xxxi. p. 337. 

2 Hutchinson : Medical Times and Gazette. 1866, vol. i. p. 194. 

3 Birkett. Medico-Chirurgical Transactions, 1869, p. 133: Moxon. Medical Times and 
Gazette, 1872, vol. i. p. 96 ; Eiedel. Beilage zum Centralbl. fur Chir., 1885. p. 92 ; Crile, 
Annals of Surgery, May, 1891. 

4 Wippermann : Arch, fur klin. Chirurgie, vol. xxxii. p. 440. 

5 In Harcourt's and Chitwood's cases, quoted by Kammerer (vide infra), the diagnosis 
is wholly untrustworthy; De Morgan gives no details. 

6 Tunnecliff: American Journal of the Medical Sciences. 1868, vol. Ivi. p. 123. 

7 Post : New York Medical Record. 1878. vol. xiii. p. 366. 

8 Lossen : Deutsche Chirurgie, Lief. 65, p. 55. 



DISLOCATIONS OF THE HIP. 7«7 

the fracture had been destroyed. Five weeks later the patient " could 
walk with one crutch, and measurement showed but half an inch short? 
ening of the limb. He has progressed favorably since that time." 

Post's patient was a girl thirteen years old who, six months before 
admission, had received a blow upon the back with " a twisting of the 
body to the right and the lower extremities to the left." Both hips 
were dislocated, and there was also fracture of the neck of the left 
femur, the head of which had become necrosed ; a sinus communicated 
with it as it lay on the dorsum ilii. The head was removed through 
an incision, and the limb straightened. The right dislocation was 
reduced by manipulation, and the patient became able to walk with 
crutches, the function of the right limb being fully restored, the left 
being shortened four and one-half inches. 

Possibly reduction might be effected by direct pressure upon the 
head under anaesthesia, but it seems unlikely. Possibly, also, reduc- 
tion could be made by pressure through a posterior incision exposing 
the head, but as the usefulness of the limb, after reduction, would 
depend largely upon the preservation of the vitality of the head and 
its union with the shaft, and as this depends upon the preservation of 
the continuity of a sufficient amount of the periosteum, it is by no 
means certain that all cases are fit for reduction or that they would 
remain so after the cutting necessary to effect it. The fact that in 
three cases the head became necrotic shows that the laceration of the 
periosteum when the fracture is through the narrow part of the neck 
is probably greater than in similar fracture without dislocation. The 
alternatives would be to await consolidation and then seek to reduce, 
as in Tunnecliff's case, or to seek a pseudarthrosis at the seat of frac- 
ture, or to correct the attitude of the limb and seek union with a view 
to the formation of a new socket for the head on the ilium, or to excise 
the head if the fracture is near it. Possibly McBurney's hook could 
be advantageously used in fracture at the base of the neck, or even 
in fracture through the neck, making the incision in front. 

Fracture of the shaft of the femur, occurring coincidently with its 
dislocation, has been observed a few times. Hamilton collected four 
cases, those of Bloxham, 1833, Thornhill, 1836, Eteve, 1838, and 
Markoe, 1853, in all of which it is claimed that reduction was effected. 
He rejects ThornhilPs claim as " altogether incredible," and doubts 
if a dislocation existed in Markoe's. In Bloxham's and Eteve's the 
fracture was near the middle of the shaft, in ThornhilPs in its upper 
third, and in Markoe's the site is not mentioned. In Bloxham's the 
dislocation was on the pubis, and was reduced on the seventh or eighth 
day by traction with pulleys, the limb having been secured with splints, 
and by direct pressure on the head of the bone. In Eteve's the dis- 
location was backward, and reduction was effected by making slight 
traction upon the upper part of the flexed thigh, and by direct pressure 
on the head of the bone. 

To these may be added Cooke's case of obturator dislocation with 
fracture just below the trochanter, quoted in Chapter I ill.. Cooper's 
of dorsal dislocation with fracture at the middle of the shaft, ami 
Delagarde's of backward dislocation witli double fracture o\' the shaft. 



788 DISLOCATIOXS. 

Cooke's patient was nine years old, and reduction was easily effected 
by direct pressure on the head. Cooper's 1 patient was a lad sixteen or 
eighteen years old ; " as the reduction of the hip was, of course, im- 
practicable," union of the fracture was alone sought at first, and after 
five weeks, the bone appearing tolerably firm, careful extension by 
pulleys was made for half an hour, and was successful. He also 
quotes 2 another case in which reduction was not made. 

In Delagarde's 3 case the dislocation was backward, and the shaft was 
broken in two places. The dislocation remained unreduced, and the 
head was subsequently excised. 

Kammerer 4 reported a suprapubic case with fracture between the 
upper and middle thirds in which reduction was not made, and collected 
twelve other cases of fracture of the shaft with various dislocations. 

Possibly reduction might be effected in dorsal cases by using the 
weight of the limb to make traction in the prone position, as described 
in Chapter LI., and in other forms traction, with pressure on the head, 
should be tried ; this failing, McBurney's hook (Fig. 304) should cer- 
tainly be tried, as it involves less laceration and gives better control 
than forceps applied through an incision. 

Associated fracture of the pelvis, usually of the rami of the pubis 
and ischium, and sometimes extending into the acetabulum, has been 
reported. It has always been caused by great violence acting directly 
upon the patient, and has usually been combined with other injuries 
which have proved fatal. 

Detachment of the Labrum Cartilagineum. Zinner 5 reports a case of 
dorsal dislocation complicated by a double vertical fracture of the 
pelvis extending from the pectineal eminence through the margin of 
the acetabulum to the tuber ischii and through the inner border of the 
inferior ramus of the pubis, and by detachment of the labrum carti- 
lagineum ; the latter was entirely torn away, with the exception of a 
small piece at its upper outer part, and, with its ends twisted about 
each other, was w T edged between the outer margin of the acetabulum 
and the neck of the femur and prevented reduction. The ligamentum 
teres was torn from the acetabulum and remained attached to the head 
of the femur and to the labrum. Detachment of a portion is prob- 
ably not rare. 

SIMULTANEOUS DISLOCATION OF BOTH HIPS. 

Simultaneous dislocation of both hips has been reported in about 
thirty cases. 6 Usually the dislocation is not the same on both sides, 
but if backward upon the ilium in one it is forward upon the obtura- 

1 Cooper : Dislocations arid Fractures, American edition, 1844, p. 40. 

2 Cooper : Loc. cit., p. 41. 

3 Delagarde : St. Bartholomew's Hospital Eeports, 1866, vol. ii. p. 183. 

4 Kammerer : New York Medical Journal, February 16, 1889. 

5 Zinner: Zeitschrift fur Heilkunde, vol. viii. p. 121; abstract in Centralblatt furChir., 
1888. p. 55. 

6 For bibliography of 26 cases see Xiehans, Deutsche Zeitschrift fur Chirurgie, 1888, 
vol. xxvii. p. 467 ; also a double dorsal dislocation, Pfeiffer, in Boston Medical and Surgi- 
cal Journal, August 4, 1887, and Lewis, Annals of Surgery, 1904, vol. xl. p. 735, with bib- 
liography to date. Tschmarke. Monatschrift fur Unfallheilkunde, 1905, No. 7. reports a 
ease and collects six others later than Xiehans. 



DISLOCATIONS OF THE HIP. 789 

tor foramen or upon the pubis in the other. The common cause is a 
heavy blow received upon the back or side while the patient is bending 
forward, by which he is twisted to one side, so that one thigh is abducted 
and the other adducted. Of this mode of production Boisnot's l case 
is a good example : a bale of goods fell upon a powerful man, forty 
years old, striking him upon the left side of the head and neck, and 
bending him to the right, and caused a dorsal dislocation on the left 
side, and a suprapubic one on the right. In Barker's case, quoted in 
Chapter LIL, both dislocations were obturator, and were caused by a 
fall from a height of about thirty feet upon a sand bank, the patient 
striking upon his feet and having them widely separated. In Schin- 
zinger's 2 case, dorsal on one side and suprapubic on the other, it was 
thought the latter might have been caused by the efforts of the by- 
standers to drag the patient from under the bank of earth that had 
fallen upon him. 

Simultaneous dislocations of the left hip backward and of the right 
knee forward and upward were reported by Brittain, 3 and of the knee 
and hip of the same side by Hulke. 4 

ACCIDENTS CAUSED BY ATTEMPTS TO REDUCE. 

Before the use of ether and chloroform to obtain anaesthesia, and 
the general substitution of milder methods in the place of forcible 
traction by pulleys, it was not rare for severe inflammatory reaction, 
and even suppuration, to follow reduction or the attempt to reduce, or 
for the patient to die in consequence of the shock and exhaustion pro- 
duced by the efforts of the surgeon. Cooper 5 says " there are plenty 
of cases on record of fatal abscesses from violent attempts at the 
reduction of dislocated hips." Such consequences are now extremely 
rare, but, even when forcible traction or other violent manipulations 
have not been employed, they must still be expected occasionally to 
occur as the result in part at least of the original traumatism. 

Fracture of the neck or even of the shaft of the femur has been 
caused in a number of cases by the surgeon in his efforts to reduce, 
either by forcible traction or by manipulation. Although in modern 
methods but little force, comparatively, is applied by the surgeon, yet 
it must be remembered that the force is habitually applied on the long 
arm of a lever of which the neck of the femur is the short arm, and 
the fracturing strain upon the latter is thereby greatly augmented. 
The fracture, apparently, takes place more frequently during rotation 
or abduction than during the flexion of the limb. In most of the 
reported cases the account is limited to the circumstances attending 
the fracture, and no mention is made of the subsequent course of the 
case. Of the 14 cases collected by Wippermann (vide supra), includ- 
ing also the one in which the fracture occurred simutaneously with 
the dislocation and another in which it probably did, the final result is 

1 Boisnot: American Journal of the Medical Sciences. October. 1807, p. 396. 

2 Schinzinger : Wiener med. Presse, 1880, quoted by Kronlein. 

3 Brittain : London Medical Gazette, 1836, vol. xviii. p. 057. 
* Hulke : British Medical Journal, 1883, vol. ii. p. 1. 

5 Cooper: Loc. cit., p. 33. 



790 DISLOCATIONS. 

indicated in 9 ; of these consolidation of the fracture took place in 3 
and failed in 6, and in two of the latter (Czerny, Bryek), in both of 
which the fracture was secondary and through the narrow part of the 
neck, an abscess formed, from which the necrotic head of the femur 
was subsequently removed. See also Kammerer, supra. 

Fractures produced during moderate manipulation in recent cases 
should be treated in accordance with the considerations affecting the 
treatment of simultaneous fracture and dislocation. 

In Stokes's fatal case of suprapubic dislocation, in which death was 
attributed to pulmonary embolus, it is impossible to say whether the 
fatal result was due to the traumatism or to the reduction. If it was 
due to pulmonary embolus the clot must have formed before reduction 
was attempted, and the latter could only have caused its detachment. 

In a case of fresh dorsal dislocation that came under my care in 
Bellevue Hospital in 1886, death occurred an hour and a half after 
the accident and half an hour after easy reduction by the weight of 
the limb in the prone position, without anaesthesia. The patient was a 
muscular young man, a worker in a brewery, and the dislocation was 
caused by a fall from a wagon. He was brought to the hospital within 
an hour after the accident, and presented marked symptoms of shock 
— restlessness, sighing, cool surface, small pulse. No autopsy. 

PROGNOSIS AND AFTER-TREATMENT. 

The prognosis after reduction in uncomplicated cases is favorable, 
the patients usually regaining good use of the limb. The inflamma- 
tory reaction is usually slight, and other treatment than rest in bed 
for two or three weeks is rarely required. Occasionally there is a 
tendency to recurrence which needs to be combated either by slight 
permanent traction upon the limb or by keeping it in an attitude that 
is unfavorable to recurrence, extension, abduction, and outward rota- 
tion after a dorsal dislocation. 

If reduction is not made the patient will be permanently crippled 
to a greater or less degree. Usually a new articular socket is formed 
by bony outgrowths about the head which permits some motion, and 
the principal disability is due to the attitude of the limb, to its lack 
of parallelism with the other, and to the necessity of tilting the pelvis 
and curving the spine in order to bring the foot to the ground ; but in 
a few cases patients have also suffered from persistent pain aggravated 
by use, and even from numbness or paralysis due to pressure on a nerve. 

In the dorsal dislocations the attitude of the limb, flexion and abduc- 
tion, adds considerably to the actual shortening, and the patient may 
be unable to walk without crutches or a support attached to the sole 
of the shoe. In unreduced suprapubic, supracotyloid, and obturator 
dislocations the attitude is often less faulty and in a number of cases 
the limb has been very serviceable. 

HABITUAL DISLOCATIONS. 

A considerable number of cases have been reported in which the 
hip could be voluntarily dislocated by muscular contraction or by 



DISLOCATIONS OF THE HIP. 791 

slight pressure upon the foot when the limb was placed in a certain 
attitude, or in which the dislocation recurred involuntarily during use 
of the limb. Perier 1 collected fifteen cases, more or less authentic, 
including one observed by himself and exhibited to the Societe de 
Chirurgie, and Hamilton nine additional ones. In some the peculi- 
arity clearly followed a traumatic dislocation, in others it was the con- 
sequence of congenital or acquired alterations in the constituent parts 
of the joint. Only the former will be here considered, the latter 
belonging more strictly in the classes of spontaneous or pathological 
dislocations. 

The two most satisfactory examples are one observed by Bigelow 2 
and another quoted by him from a report furnished by Dr. E. M. 
Moore ; both were dorsal. In Bigelow's case " the hip was dislocated 
while the legs were crossed, a wagon in which the man was riding 
having pitched into a hole. In a few hours the hip was reduced by 
flexion. Eight days after the accident, in attempting to walk upon 
the limb, it was again partially luxated, when the patient himself 
replaced it by pushing against it with one hand and pressing with the 
other against his knee. Since that time both luxation and reduction 
have been comparatively easy, and the patient now displaces the head 
of the bone backward upon the edge of the socket by muscular action, 
and reduces it by throwing the leg out sidewise. The luxation is 
sometimes attended with pain, and the prominence caused by the head 
of the luxated bone is sensitive to the touch. The displacement is 
rather a subluxation, and the limb exhibits slight flexion, shortening, 
and inversion. 7 ' 

Dr. Moore's patient was a soldier, who, while " skirmishing up a 
hill, sprang back suddenly to avoid the gun of a comrade in advance. 
His left foot became entangled, and his weight dislocated his hip. He 
felt the injury, and supposed it out of joint. Some comrades pulled 
it in. He immediately resumed skirmishing, and marched seven miles, 
from 10 A.M. until 6 p.m. He lay down at night, and went on duty 
the next day, sharp-shooting, crawling all day. He continued this 
kind of duty five days, and returned to camp, when he was imme- 
diately put in intrenchments, and worked two days and two nights. 
Afterward he went on picket, and entered the hospital on the sixteenth 
day after the accident. At present he can luxate the hip-joint at any 
time, and does it by pressing the foot on the floor to fix it firmly, con- 
tracting the adductors, and throwing out the pelvis. The head sud- 
denly leaves the acetabulum and goes on the dorsum ilii." 

As no autopsy has been reported in any such case, the explanation 
of the peculiarity can only be inferred. It is probable that the rent in 
the capsule is insufficiently repaired, and the edge of the acetabulum 
lowered at the point where the head of the femur escapes. 

1 Perier : Bull, do la Soc. do Chir., 1859, vol. x. p. 12. a Bigelow: The Hip. p. 112, 



'92 DISLOCATIONS. 



TREATMENT OF OLD, UNREDUCED DISLOCATIONS. 

Hamilton collected fifteen cases in which it was claimed that reduc- 
tion had been successfully accomplished after the lapse of long periods, 
and shows that but few, if any, of them can be deemed trustworthy ; 
in a number of them the dislocation was clearly not traumatic, and in 
the others the reports are brief and unsatisfactory. Sir Astley Cooper's 
statement that eight weeks was the period after which it would be 
imprudent to attempt reduction has been taken rather too literally, 
and the sounder judgment is that the question is to be determined by 
other facts than the simple length of time that has elapsed, such as 
the distance of the head from the acetabulum, its mobility, the degree of 
the inflammatory reaction, the usefulness of the limb, and the health or 
constitution of the patient. 

The operative measures that have been employed either to effect 
reduction or to improve the functional condition of the limb are open 
arthrotomy, osteotomy or fracture of the neck or shaft, and excision of 
the head or of the head, neck, and trochanter. 

The first is applicable to relatively recent cases which are thought 
to be not absolutely irreducible, to be supplemented in case of failure 
by excision. The others are applicable to older cases, as palliative 
measures designed to improve the position of the limb and make it 
movable. 

Resort to open arthrotomy * appears to be increasing quite rapidly. 
The earlier results, within the antiseptic period, were not favorable, 
reduction failing in about two-thirds of the attempts, with subsequent 
resort to excision of the head, but changes in the technique have brought 
improvement. The important factors are (1) an operative method which 
will give free access to and permit easy removal of the obstacles so that 
forcible manipulations and consequent laceration will not be necessary, 
and (2) successful asepsis. The first minimizes the chance of death by 
shock ; the second is essential to the maintenance of mobility in the 
joint and the securing of a good functional result, besides avoiding the 
later risks to life. 

The important obstacles earliest to form are adhesions and cicatrices, 
mainly on the side toward which the head has been displaced ; later 
and less frequent ones involve the socket and the portion of the capsule 
which crosses it, and the retraction of the muscles shortened by the 
displacement. It is often difficult to find a method of approach which 
will make it easy to deal with all these obstacles, for they may lie on 
opposite sides of the neck. It is also important not to damage the peri- 
osteum of the neck and the soft parts at its base, lest the destruction 
of their vessels should cause necrosis of the head, as has happened in 
several cases. A forcible attempt to reduce, pushed to the production 

1 For bibliography see 1st edition ; Kirn, Beitrage zur klin. Chir., 1889, vol. iv.p. 537; 
Harris, Annals of Surgery, September, 1894; Engel, Arch, fur klin. Chir., 1897, p. 629; 
Sherman, Phil. Med. Jour., August 20, 1898 ; Hoflinger, Centralblatt fur Chir., 1901, p. 310 ; 
Payer, Beilage zum Centralblatt fur Chir.. 1901, p. 141 ; Gayet, Bevue de Chir., 1902, vol. 
xxvi. pp. 41 and 269, 29 cases ; Maydl, Centralblatt fur Chir., 1903, p. 678, 15 cases ■ 
Eydygier. ibid., 1904, 377. 



DISLOCATIONS OF THE HIP. 79:} 

of lacerations, should not immediately precede the operation or form a 
large part of it, lest suppuration should ensue notwithstanding antiseptic 
precautions. It is noteworthy that suppuration occurred in half of the 
twenty-four cases collected by Hoflinger. 

The incisions employed in dorsal dislocations have been a straight 
anterior one along the inner side of the sartorius, a posterior one from 
the base of the trochanter to its tip, passing thence backward parallel 
to the fibres of the gluteus (Kocher's resection incision), and a convex 
external one (Oilier), the centre of which passes two and a half inches 
(Rydygier) below the tip of the trochanter, its posterior portion running 
toward the posterior superior spine of the ilium, and its anterior toward 
the anterior superior spine. The trochanter is cut off obliquely and 
reflected upward with the attached muscles. Rydygier says this gives 
a full exposure of and easy approach to the head and socket, and the 
obliquity of the bone section permits the fragment to be brought back 
into contact even if not fully into place and thus favors bony reunion. 
Each incision has its partisans, and each probably its more suitable 
cases. 

Steissler l reports one case and collects twenty others of anterior dis- 
location, fifteen of them obturator, in which excision, osteotomy, or 
operative reduction was done. The anterior and the external incisions 
have been used. 

Excision of the head, or of the head, neck, and trochanter, has been 
done in a considerable number of cases, either primarily or after the 
failure of an attempt to reduce. 2 

Osteotomy, through or below the neck, has been done by Van Wahl 
and Kock 3 and by Villeneuve 4 after failure to reduce by arthrotomy ; 
in two the reported result was good, in the third (Kock) the bone 
healed in a faulty position. 

In deciding whether or not to interfere in an old case, and in choos- 
ing a method if interference is determined upon', several things beside 
the mere fact of the existence of the dislocation must be considered. If 
the limb is useful, if the patient is not suffering from pressure effects, 
and if he is no longer young, prudence will often dictate abstention. 
Quieta non movere ! Or, at the most, an osteotomy may be done to 
bring the limb into a more convenient and serviceable position. If the 
patient is younger, if the disability is greater, if the position of the 
head causes serious pressure effects, reduction by arthrotomy may be 
attempted, with the determination to abandon the attempt if it proves 
difficult and to substitute excision. But the surgeon mast carefully 
consider the present usefulness of the limb, the probability of the use- 
fulness that will follow the interference, and the risk to life incurred in 
the attempt to improve. 

1 Steissler: Beitrage zur klin. Chir., 1908, vol. lviii. p. 571. 

' 2 Delagarde, St. Bartholomew's Hospital Reports, 1866, vol. ii. p. 183 ; Sydney 
Jones, Lancet, 1884, vol. ii. p. 870; Ratimow. St. Petersburg Med. Wochenschrift, 
July 30, 1888; Graziana, Centralblatt fur Chir., 1890, p. 244; Kammerer. Medical 
Record, March 4, 1893; Flower, British Medical Journal, Nov. 2, 1895; Browne, Ibid., 
February 15, 1896; Ostermayer, Centralblatt fur Chir., May 11, 1S95; Paci, Arch. 
Italian, de Pediat., vol. vii. 

3 Van Wahl and Kock : Berlin, klin. Woch., 1S82, p. 492. 

4 Villeneuve . Rev. d'Orthopgdie, 1892, p. 161. 



794 DISLOCATIONS. 

Subcutaneous fracture of the neck has never, so far as I know, been 
intentionally done to correct a vicious position of the limb, but in a 
number of cases in which it has occurred during an attempt to reduce 
it has been utilized for this purpose and with good results, although, 
above mentioned, necrosis of the head of the femur has twice ensued. 

CONGENITAL DISLOCATIONS. 

(See Chapter XXXY.) 

SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS. 

Almost all the different kinds of spontaneous dislocation have been 
observed at the hip, and many of them with a frequency that has not 
been observed at other joints. The weight of the body in walking is 
a factor of much importance and constantly at work, the effect of 
which is well shown in three cases reported by Liicke, 1 in which the 
dislocation followed rhachitic changes in the shape of the femurs and 
the spinal column. The patients were children who, at birth and 
during infancy, showed no sign of dislocation ; after a time rhachitic 
changes occurred, the displacement appeared ; and walking became 
difficult. Lucke found a marked lumbar lordosis and anterior curva- 
ture of the femurs ; the trochanters were displaced far backward, and 
the dislocation was evident. He thought the curvature of the femurs 
was the primary change, and the lordosis compensatory of it, and that 
the dislocation was due to changes in the acetabulum following the con- 
sequent pressure at an unusual point. 

Of similar character are those cases in which the dislocation has 
taken place in a healthy joint in consequence of the prolonged main- 
tenance of some exceptional attitude, as in a case reported by Franks 2 
of a child five years old, who had been confined to the bed for many 
months by an arthritis of the left hip, and had lain upon its left side 
with the knees and hips flexed, and the right hip adducted ; a dorsal 
dislocation took place without pain on the right side. Here the con- 
traction of the muscles takes the place of the weight of the body in 
producing the dislocation when the limb is long held in a favorable 
attitude, and many examples of this effect have been reported in cases 
in which the joint was the seat of an arthritis, as in acute articular 
rheumatism, or in continued fevers, typhoid, scarlatina, in which usu- 
ally there are indications of inflammation of the joint, although in 
some cases attention was first called to the joint by the appearance of 
the deformity. (See p. 498.) As the individual usually lies with the 
thigh flexed and adducted, the dislocation almost always takes place 
backward and upward ; but in a case observed by Stromeyer, 3 a man 
eighteen years old, affected with acute articular rheumatism, especially 
of the hip, during the entire course of which he had lain on his side, 
the dislocation was into the obturator foramen. 

1 Liicke : Quoted by Forgue and Maubrac, Luxations pathologiques, Paris, 1886, 
p. 15. 

-Franks: Lancet, 1883, vol. ii. p. 15. 

3 Stromeyer: Handbucb der Chir., 1844, vol. ii. quoted by Forgue and Maubrac. 



DISLOCATIONS OF THE HIP. 795 

"Paralytic" or "myopathic" dislocations of the hip, those in 
which the displacement is effected by the unopposed contraction of cer- 
tain muscles or groups of muscles, whose antagonists are paralyzed, 
have been most frequently seen as a consequence of infantile paralysis. 
As has been shown in Chapter XXXVI. they were formerly con- 
founded with congenital dislocations, and were first clearly separated 
from them by Verneuil, 1 and afterward studied in detail by some of 
his pupils, especially Reclus. 2 When the paralysis involves all the 
muscles of the hip the joint becomes loose, and the femur may be dis- 
placed and replaced at will, but when only a part of the muscles are 
paralyzed the contraction of the others leads to a permanent displace- 
ment. If the posterior muscles are paralyzed, and the adductors 
remain in good condition, the dislocation is dorsal ; if the adductors 
are paralyzed and the glutei remain sound, the dislocation is forward 
upon the pubis. One of the cases observed by Reclus may be taken 
as a good example of one form ; a child, which had previously been 
healthy and well formed, was attacked at the age of seven years with 
high fever and a paralysis which, at first general, became localized in 
the glutei and the other pelvi-trochanteric muscles ; the other groups, 
especially the adductors of the thigh, recovered their activity ; a well- 
marked dorsal dislocation followed. 3 

In a case reported by Bradford,* a girl, eighteen months old, the 
right thigh was flexed and abducted at a right angle, the adductors 
were paralyzed, the glutei and tensor vaginae femoris sound. The head 
of the femur could be felt in the groin upon the superior ramus of the 
pubis midway between the symphysis and the anterior superior spine 
of the ilium. Reduction was effected, but the limb remained almost 
powerless. 

The cases should be treated by prompt reduction, if possible, and 
the maintenance of the limb in an attitude that opposes recurrence. 

In three cases reported by Roser 5 in 1885, at the Congress held at 
Strasburg, the paralysis was due to spinal disease ; in one of them the 
patient produced the dislocation by swinging his legs forward while 
walking with crutches ; in the other two the dislocation took place in 
bed without appreciable cause. 

The limitation of the paralysis to one group of muscles is to be 
explained by the fact that the adductors are supplied by the obturator 
nerve, a branch of the lumbar plexus, and the posterior muscles by 
branches of the sacral plexus, and that the medullary centres of these 
nerves are at different points in the cord, that of the former being at 
a higher point than the other, probably at the upper part of the lumbar 
enlargement. 

Dislocations due to destruction of the bony parts of the joint by 
tubercular disease are comparatively common; their consideration 
belongs rather to the subject of disease of the hip-joint, 

1 Verneuil : Bull, de la Soeiete de Chirurgie, 1866. 

2 Reclus: Eevue de Med. et de Chir., 1878, p. 17t>. 

3 See paper by Karewski, Arch fiir klin. Chir., 1888, vol. xxxvii. p. 346. 

4 Bradford : Boston Medical and Surgical Journal, 1883, vol. cviii. p. 73. 

5 lioser ; Quoted by Forgue and Maubrac, loc. cit., p. 4o. 



796 DISLOCATIONS. 

In like manner the consideration of those dislocations which follow 
changes in the bones produced by chronic rheumatism or dry arthritis 
or in ataxia belongs to works upon those subjects. The alterations in 
the shape of the bones, either by atrophy or by hypertrophy, are 
so marked that reduction or maintenance of reduction is impossible. 
In dry, or deforming, arthritis not only are all the constituent parts of 
the joints involved in the changes, but the muscles also become degen- 
erated ; the bones are usually hypertrophied by outgrowths at the bor- 
ders of the articular surfaces, they lose their articular cartilage, and 
become eroded at points of contact. The changes in locomotor ataxia 
are characterized by early and rapid atrophy of the head and neck of 
the femur with destruction to a greater or less extent of the rim of the 
acetabulum. Sometimes dislocation takes place abruptly with well- 
marked and characteristic symptoms ; in other cases the symptoms are 
more like those of fracture of the neck of the femur, the foot is everted 
and the trochanter raised, but the movements are exceptionally free 
and may be painless. 



CHAPTER LIV. 

DISLOCATIONS OF THE KNEE. 

Forward — Backward — Lateral — Antero-lateral — By Rotation — Dislocation of 
the Semilunar Cartilages — Congenital — Spontaneous or Pathological Dis- 
locations. 

Anatomy. 

The knee-joint may be regarded as composed of two joints, of 
which one is formed by the patella and femur, the other by the femur 
and tibia ; and the latter is composed of two parts, differing somewhat 
from each other, each of which is formed by one of the condyles of the 
femur and the corresponding portion of the upper surface of the tibia. 
The condyles of the femur are separated from each other by the inter- 
condylar notch, and between the condylar surfaces of the tibia is a 
depression which is interrupted in the centre by the spine. 

The ligaments which bind the femur to the tibia and fibula are the 
external and internal lateral, the posterior, and the crucial. The 
internal lateral ligament, long and flat, extends from the internal 
tuberosity of the femur to the inner side of the shaft of the tibia ; the 
external lateral, more rounded and cord-like, extends from the exter- 
nal tuberosity of the femur to the head of the fibula, overlying the 
tendon of the popliteus above and being embraced by the tendon of the 
biceps below. The short external lateral ligament, lying someAvhat 
more deeply and posterior to the other, is attached above to the 
side of the condyle and below to the styloid process of the fibula. The 
posterior ligament is attached above to the upper part of the intercon- 
dylar fossa of the femur and below to the posterior margin of the 
head of the tibia. The crucial ligaments extend from either side of 
the intercondylar notch to the depression in front of and behind the 
spine of the tibia. In full extension of the knee these ligaments are 
made tense, but in flexion at a right angle the lateral ones, especially 
the external lateral, are relaxed. 

The semilunar fibro-cartilages are intra-articular structures attached 
to the head of the tibia at their outer margins and ends and having 
free smooth surfaces above and below ; they are triangular on vertical 
section, the peripheral border being thick, the central thin ; as they are 
rings, not disks, each leaves the corresponding condylar surface of the 
tibia uncovered at the centre. The internal one is semicircular, and 
its ends are attached in front of and behind the spine of the tibia 
respectively ; the external one is nearly a complete circle, and its ends 
are attached to the spine of the tibia between those of the internal one, 
its posterior end is also attached to the inner condyle of the femur in 
connection with the posterior crucial ligament. The external cartilage 



798 DISLOCATIONS. 

is movable upon the tibia, this freedom of motion being utilized in the 
outward rotation of the leg which occurs at the end of extension, while 
the internal one is more fixed and serves mainly to make a more con- 
cave surface for articulation with the internal condyle of the femur. 
The anterior borders of the two cartilages are connected together by 
a slight transverse band, the transverse ligament ; it is sometimes 
lacking. 

The capsular membrane fills the gaps between the ligaments. It is 
reinforced on each side by broad fibrous sheets attached to the sides of 
the patella and derived from the fascia lata and the muscles, the 
so-called lateral expansions. 

The synovial membrane extends well up on the front of the thigh, 
frequently communicating with a bursa under the quadriceps, and 
invests the crucial ligaments by a reflection from the posterior wall. 
Between the tibia and patella it rests upon a mass of fat, forming two 
lateral folds, the alar ligaments, and sending backward from its middle 
another fold, the ligamentum mucosum, which is attached to the front 
of the intercondylar notch. By these folds and the crucial ligaments 
the joint is divided into three more or less freely communicating com- 
partments. 

Functionally, the femoro-tibial joint is a ginglymo-arthrodial, its 
movements being effected by a combination of gliding, rolling, and 
rotation of the bones upon each other. In complete extension no rota- 
tion is possible, but as the knee is flexed outward rotation appears and 
increases, reaching 21 degrees at rectangular flexion and 31 degrees at 
flexion 30 degrees within a right angle. (Mayer.) 

In complete extension the patella rests upon the upper part of the 
trochlear surface of the femur, and as flexion is made it moves down- 
ward and is gradually turned outward by the increasing prominence of 
the internal condyle, so that at the last it rests by its upper and outer 
facet on the front of the external condyle and by its inner facet against 
the narrow surface of the outer margin of the internal condyle. As 
the movement of extension approaches its limit the tibia undergoes 
slight outward rotation in which the external semilunar cartilage does 
not participate, that is, the outer condylar surface of the tibia moves 
backward under the fibro-cartilage ; correspondingly, when flexion is 
begun from the position of complete extension it is accompanied by 
inward rotation of the tibia. The limitation of extension is affected 
by the posterior and lateral ligaments, that of flexion by the contact of 
the soft parts of the calf and thigh and of the posterior margin of 
the semilunar cartilages with the back of the condyles of the femur. 
Displacement of the tibia forward, backward, or to either side is op- 
posed by the lateral and crucial ligaments. 

Statistics. 

Dislocations of the knee, of the femoro-tibial joint, are rare, con- 
stituting about 1 per cent, of all cases. They are divided according 
to the direction in which the tibia is displaced into forward, backward, 
outward, and inward dislocations, and dislocations by rotation. Mai- 



PLATE LXIII 




Fig. 1. — Anterior Dislocation of the Knee. 




Fig. 2.— Posterior Dislocation of the K' 



DISLOCATIONS OF THE KNEE. 799 

gaigne made additional groups of intermediate forms. The disloca- 
tion may be complete or incomplete, simple or compound. A tabula- 
tion which I made by the aid of the references to periodical literature 
in the Index- Catalogue of the Surgeon-Genei*aVs Library showed that 
of 114 traumatic cases the dislocation was forward in 52, backward 
in 34, outward in 21, inward in 4, " lateral " in 1, and by rotation 
in 3. In 21 of them the dislocation was compound; 11 forward, 4 
backward, 6 outward. 

The injury is very rare in childhood, the two youngest patients in 
my list being aged ten and eleven respectively ; it is of exceptional 
gravity because of the size of the joint, because it is usually caused by 
great violence, and because of the frequency with which it is compound 
and with which the popliteal vessels are injured. Amputation has been 
resorted to in a large proportion of cases. Simultaneous dislocation 
of both knees has been observed in a few cases. 

DISLOCATIONS FORWARD. 

These may be complete or incomplete, simple or compound. The 
complete seem to be very much rarer than the incomplete ; the com- 
pound occur in an exceptionally large proportion, 18 per cent, in the 
tabulation just given, and the wound is habitually made by rupture of 
the soft parts posteriorly where they are stretched across the projecting 
condyles of the femur in hyperextension of the leg. 

The cause may be either hyperextension of the leg, or violence 
received upon the front of the thigh or the back of the leg near the 
knee. The former appears to be much the more common ; in it the 
tibia turns upon its anterior margin as a centre, putting the posterior, 
lateral, and crucial ligaments upon the stretch, and after their rupture 
it glides forward along the condyles, or the condyles slide backward 
along it. The hyperextension may be produced by a force applied to 
the back of the leg or foot, or, more commonly, by the propulsion of 
the trunk and thigh while the leg is held stationary and upright ; 
thus, a man running down a hill steps into a hole, the leg entering to 
its upper third, and falls forward. In a case of my own the patient, 
a large heavy man, was standing in an elevator which was sud- 
denly stopped while descending rapidly; he received the dislocation 
without falling or being struck, apparently by hyperextension of the 
knee. The tibia overrode the femur one and a half inches. The 
other cause, direct violence, may act upon the front of the knee while 
the leg is either extended or partly flexed. In another set of cases, 
of which I have met with the records of four examples, the mode of 
production is not clear ; the patients were caught in rapidly revolving 
wheels or shafts and whirled around many times, the body passing at 
some part of its course through a narrow space ; in three of those cases 
both knees were dislocated, in two of them one dislocation being for- 
ward, the other backward, and in the third one dislocation was forward 
and the other inward. 

In a case of my own in which the patient was similarly caught bv 



800 DISLOCATIONS. 

a shaft he was wedged against the ceiling, but not carried through, 
receiving forward dislocations of both knees, one compound on the 
inner side with rupture of all the internal hamstring muscles through 
their fleshy parts well above the joint. He made a good recovery, but 
eight months later paralysis of the external popliteal group persisted 
on one side, and control of the knee was defective on the side on which 
the muscles had been torn. With the aid of a brace for that knee and 
a rubber muscle for the paralyzed anterior tibial group he was able to 
walk and work. 

In a case reported by Cotton l the ligaments of the joint had gradu- 
ally grown so weak that the knees bent backward ; as the patient got 
out of bed one morning a compound dislocation, with rupture of the 
popliteal artery, was produced. 

Pathology. In the incomplete form, that in which the upper articu- 
lar surface of the tibia is still in contact by its posterior portion with 
the inferior surface of the condyles, the injury to the ligaments and 
other soft parts appears to be slight ; in the only autopsy, one reported 
by Desormeaux, 2 the anterior crucial ligament alone was torn, and that 
only in part. In the complete form, on the other hand, the injuries 
are very extensive ; one or both lateral ligaments, one or both crucial, 
the posterior, and the lateral ligaments of the patella are completely 
ruptured or widely torn. The posterior muscles, the biceps, gastrocne- 
mius, popliteus, even the soleus and vastus internus are lacerated or 
divided; the internal and external popliteal nerves may be torn or 
bruised, the popliteal artery and vein ruptured, the skin of the poplit- 
eal space torn through. Sometimes the ligaments are ruptured, some- 
times they are torn from the femur, perhaps bringing with them 
portions of the bone ; the protruding condyles appear sometimes as if 
they had been cleaned with a knife. The overriding of the tibia and 
femur may amount to two or even three inches ; in Mayo's 3 it was said 
to be fully four inches. 

The injuries to the popliteal artery are of exceptional interest and 
importance. Its inner and middle coats may be torn completely across 
(Annandale, Cotton, Knichynicki, 4 Lowe, 5 two cases, Vevers, 6 and 
Stewart and Turner, quoted by Spillmann ; in most of them the dislo- 
cation was compound) ; or, as in a case examined by Malgaigne, there 
may be several small rents at atheromatous, calcareous points. The 
artery may be simply compressed and remain competent to perform its 
functions when the pressure is removed (Davis, 7 Hixon 8 ), or it may 
be so bruised that a thrombus will subsequently form (Brittain). The 
popliteal vein appears from the reports to have been less frequently 
torn, but when bruised it also may become occupied by a thrombus. 
It seems probable that in the cases in which gangrene followed the 
vein as well as the artery was injured. The opportunities for direct 

1 Cotton : Proceedings of the Connecticut Medical Society, 1880, vol. ii. p. 54. 

2 Desormeaux : Bull, de la Soc. de Chirurgie, 1853, vol. iii. p. 367. 

3 Cooper : Loc. cit., p. 187. 

* Knichynicki : Allg. Wiener med. Zeitung, 1873, vol. xviii. p. 255. 

5 Lowe : St. Bartholomew's Hospital Beports, 1869, vol. v. p. 80. 

6 Vevers : Lancet, 1869, vol. ii. p. 542. 

7 Davis: Philadelphia Medical Times, 1876-77, vol. vii. p. 270. 

8 Hixon : North American Medico-Chirurgical Eeview, 1858, voJL it. p. 76. 



DISLOCATIONS OF THE KNEE. 801 

examination after death or amputation have been numerous ; among 
the reports may be mentioned those by Malgaigne, Volkmann, 1 Albert, 2 
Birkett, 3 Annandale, 4 Brittain, 5 Madelung, 6 Spillmann, 7 and Lowe, 
above quoted. 

Symptoms. The leg is usually in almost complete extension, and 
when viewed from the side it is seen to lie in a plane more or less ante- 
rior to that of the thigh, according as the dislocation is complete or 
incomplete ; it may be hyperextended or partly flexed, and may be 
rotated in either direction. The outlines of the projecting condyles 
can be seen and felt in the popliteal space, and above the tibia in front 
lies the patella, more or less horizontal and freely movable, and the 
skin above it shows marked transverse folds ; the flat articular surface 
of the tibia can be felt on each side of the ligamentum patella. In 
the incomplete form the deformity is less marked, and the diagnosis 
may be difficult if the region is swollen. 

The limb may be fixed in its position, or it may be movable in any 
direction, hyperextension, flexion to a right angle, or laterally. 

If the skin is broken the rent is transverse and posterior, and 
through it one or both condyles may project, or the finger can be 
readily passed into the joint. The 
main vessels and the internal pop- ' 

liteal nerve commonly lie in the ^JLl^ a 

intercondylar notch, and may 
sometimes be plainly visible. 

Injury to, or compression of, 
the artery is shown by the loss of 
pulsation in the arteries of the 
foot and ankle ; injury to the 

, i n j_> External condyle of femur 

nerve by loss of sensation or , x . _. , .. _, . 

. •> , , , . Anterior dislocation of the knee. 

numbness, and, later, by changes 

due to defective nutrition of the limb and by pain, sometimes severe. 

The course after injury to the artery is well shown in the report of 
Annandale's case, that after injury to the nerve in Le Dentil's. 8 
Annandale's patient complained that the foot felt cold, but sensation 
in the toes was normal ; the dislocation was easily reduced, and the 
patient did well for a week ; then it was noticed that the foot was livid 
and cold. Two days later blebs had appeared upon it, and the discol- 
oration had advanced upon the leg ; three days later the signs of gan- 
grene were marked, and the limb was then amputated above the knee. 
The inner and middle coats of the popliteal artery, which were ather- 
omatous, were torn about an inch above its bifurcation, and curled 
inward ; the vessel was plugged by a firm clot. 

Le Dentil's patient, a man twenty-seven years old, was caught in 
the belt of machinery and whirled around rapidly, his legs striking 

1 Volkmann : Beitriige, zur Chir., p. 119. 

2 Albert: Wiener med. Presse, 1872. 3 Birkett : Lancet, 1850, vol. ii. p. 703. 
* Annandale: Lancet, 1881, vol. ii. p. 903. 

5 Brittain : London Medical Gazette, 1836, vol. xviii. p. 257. 

6 Madelung : Berlin, klin. Wochenschrift, 1873. 

7 Spillmann : Diet, encyclop. des Sc. Med., art. Genou, p. 000. 

8 Le Dentil : Bull, de la Soc. de Chirurgie, 1880, p. 591. 

51 




802 DISLOCATIONS. 

each time against the ceiling ; he received a complete dislocation for- 
ward of the right knee, and a complete backward dislocation of the 
left one ; the latter was reduced immediately, the former on the next 
day. On the nineteenth day the patient complained of sharp pain in 
both legs, and on examination an eschar as large as a fifty-cent piece 
was found on the left calf, and another over the right tendo Achillis : 
the former healed promptly, the latter increased, and part of the tendon 
sloughed. The pain became very severe in the right leg, it was neu- 
ralgic in character, a sensation of numbness with darting pain in the 
foot and sometimes in the leg, recurring especially at night. It per- 
sisted until the thirty-fifth day, and returned a week later. On the 
forty-fifth day another eschar appeared on the sole of the right foot 
opposite to the head of the first metatarsal bone. Sensation, which 
had previously been dulled in front, was now entirely lost throughout 
the right leg, except in the region supplied by the long saphenous 
nerve. Four days later the pain ceased, and the eschars began to heal. 
Seven months after the accident the patient returned to the hospital ; 
there was considerable atrophy of the right leg, loss of power in the 
muscles that move the foot and toes, and some stiffness at the ankle. 
The movements of both knees were normal, and the ligaments appeared 
to have reunited solidly. The patient limped in walking, but the limp 
was due solely to the atrophy of the muscles and to the persistence on 
the outer side of the sole of the right foot of one of the three ulcera- 
tions that had appeared upon the foot and heel. The trophic troubles 
were attributed to a neuritis of the popliteal nerves occasioned by their 
laceration or bruising at the time of the accident. 

Paralysis of the muscles of the outer side of the leg has been ob- 
served in three other cases, Brand, Unruh, and Poinsot, 1 in one of 
which, however (Brand), the fibula had been broken at its upper end. 

Of the compound cases, several recovered with good use of the 
limb ; in others, amputation or excision of the joint was done. 

The prognosis is grave in the compound cases and in those in which 
the artery has been injured, and it is not very favorable even in the 
simpler ones. It must be remembered that gangrene may delay its 
appearance until the second or even the third week, and that even in 
some simple cases which have done well for a week or two suppuration 
of the joint has ultimately occurred. Even after simple dislocations 
that have done well there is ordinarily some limitation of the move- 
ments of the joint. 

Treatment. Reduction is easy by traction and coaptation of the ends 
of the bones ; ordinarily, no more force is required in the traction than 
an assistant can make with his hands. Flexion of the knee to an 
acute angle has proved successful. The suggestion that the leg should 
be hyperextended, and the head of the tibia then pressed directly down- 
ward, is a dangerous ore, because of the chance of injury to the pop- 
liteal vessels. 

The rule of conduct in the presence of compound dislocations, and 
of those in which there is evidence of injury to the popliteal artery, 
has been the subject of recent discussion. Several compound disloca- 

1 Poinsot : Translation of Hamilton, p. 1142. 



DISLOCATIONS OF THE KNEE. 803 

tions in which the artery was intact have recovered, and even with full 
subsequent use of the joint, and I believe that the conservation of the 
limb under such circumstances should be attempted. 

The same rule should be followed in case of arrest of pulsation in 
the distal arteries ; that is, the surgeon should wait until it has become 
evident that the vitality of the limb is lost. If the gangrene is dry 
little is to be feared from delay, but if the limb becomes swollen and 
discolored, with loss of sensation, indicating arterial supply and venous 
obstruction, delay is more dangerous and the formation of a line of 
demarcation cannot be safely av/aited. 

DISLOCATIONS BACKWARD. 

These may be complete or incomplete ; in the former the head of 
the tibia is displaced backward and upward behind the condyles ; in 
the latter it still remains partly in contact by its upper surface with 
the condyles. 

The common cause is direct violence received upon the upper end of 
the tibia in front, or upon the lower end of the femur behind, but in 
some cases the application of the force is more indirect, as when the 
body and thigh are forced forward while the leg is held. In four cases 
the patients were caught in machinery and whirled around ; and in 
one case a boy, eleven years old, suffered a compound dislocation by 
having his leg caught between the spokes of a wagon-wheel. 

Pathology. The posterior ligament is torn, and usually one or both 
of the lateral ligaments ; in a case of complete dislocation with rupture 
of the popliteal artery (quoted by Malgaigne l ) in which Robert resorted 
to amputation, all the ligaments were intact except for two rents, each 
three centimetres long, in the posterior portion of the capsule through 
which the tibia protruded. It seems likely that the crucial ligaments, 
or at least the posterior one, must also be ruptured. The muscles 
which bound the popliteal space have been reported untorn, but widely 
infiltrated .with blood ; and in other cases one or both heads of the 
gastrocnemius and the popliteus have been torn. The semilunar 
cartilages may be in part detached or otherwise injured. In a case 
reported by Vast 2 a portion of the tubercle of the tibia had been 
torn off by the strain upon the ligamentum patella?. The popliteal 
vessels, both artery and vein, are sometimes completely torn across, 
and sometimes only the inner and middle coats of the artery are torn, 
an injury the consequences of wdiich may easily be as serious as those 
of complete rupture. This injury is produced by the forcible stretch- 
ing of the vessels across the sharp posterior margin of the head of 
the tibia. 

The patella may be drawn directly downward so as to lie below its 
normal position, or it may be displaced outward to the side of the con- 
dyle. In a case reported by Fitzgerald 3 the patella was broken into 
several pieces, and the joint was opened at the end of a fortnight by 
the sloughing of the overlying skin. The injury was caused by the 

1 Malgaigne: Loc. cit., p. 945. a Vast : Bull, de la Soc. do Chirurgie, 1877, p. 688 

3 Fitzgerald: Australian Medical Journal, 1882, p. 554. 



804 DISLOCATIONS. 

fall of a heavy case upon the front of the knee. The joint suppurated, 
but the patient recovered without entire loss of mobility. 

As complications, fracture of the femur above the condyles, Testut, 1 
and fracture of the tibia just below the knee, Adams, 2 have been re- 
ported ; also rupture of the tendon of the quadriceps femoris, Walsh- 
man, 3 Lossen. 4 

Symptoms. The leg is usually hyperex tended upon the thigh, the 
antero-posterior diameter of the knee notably increased, the head of 
the tibia placed behind its usual position, and, in the complete disloca- 
tions, also above the level of the lower surface of the condyles of the 
femur. The leg may also be deviated somewhat to either side, and 
exceptionally it may be flexed. The head of the tibia can be felt in 
the popliteal space, and a marked depression exists below the condyles 
of the femur in front. The patella may lie against the front part of 
the under surface of the condyles, or may be displaced to the outer 
side, or rotated upon its axis. The amount of shortening is slight in 
the incomplete form ; in the complete form it may be one or two inches. 

Pressure upon or rupture of the popliteal artery is manifested by 
absence of pulsation in the posterior tibial and dorsalis pedis arteries, 
and may result in gangrene of the limb. 

The diagnosis is not difficult; and as reduction is usually easy the 
prognosis in simple, uncomplicated cases is good; but attention should 
always be paid to the presence or absence of pulsation in the distal 
branches of the artery, both before and after reduction. 

In some reported cases in which the dislocation has remained unre- 
duced, the patient has had good use of the limb. Two such are the 
cases of Bagnall-Oakeley 5 and Karewski. 6 The former's patient was 
a man, seventy-years old, who had dislocated his left knee at the age 
of nine months ; he had always made full use of the limb, and had 
earned his living as a brickmaker. A false joint had formed between 
the femur and tibia, which permitted 15 degrees of flexion. The foot 
and leg were normally developed ; the thigh had an abnormal anterior 
curvature. The patella could not be recognized, and w r as thought to 
have become united with the femur. The different prominences of 
the lower end of the femur were absolutely subcutaneous and seemed 
ready to perforate the skin, but there was no trace of previous ulcera- 
tion. 

Karewski's patient Avas a servant girl, thirty-two years old, whose 
dislocation had existed for more than sixteen years. The right limb 
presented a typical dislocation backward, and when viewed from 
behind looked like a genu recurvatum, while when seen from in front 
and the side the thigh overhung the leg to a certain extent. The 
muscles of the calf were somewhat atrophied ; the nerves and vessels 
stretched above the tibia like tense cords. The growth of the bones had 
been materially affected, the tibia being three centimetres shorter than 
the other, and also thinner ; while the femur was lengthened by three 

1 Testut: Bordeaux Medical, 1874. 2 Adams : Lancet, 1881, vol. ii. p. 1108. 

3 Walshnian : Quoted by Cooper, loc. cit., p. 190. 
* Lossen : Deutsche Chirurgie, Lief. 65, p. 131. 

5 Bagnall-Oakeley: Lancet, 1882, vol. i. p. 53. 

6 Karewski : Arch, fur klin. Chir., 1886, vol. xxxiii. p. 525. 



DISLOCATIONS OF THE KNEE. 805 

or four centimetres. The overriding of the tibia and femur was four 
centimetres. Flexion and extension were normal, both actively and 
passively, and although there was much lateral mobility the functions 
of the limb were admirably performed. Pain was felt only after excep- 
tional use. 

In Lossen's case, in which reduction was attempted at the end of 
six weeks and failed, the patient finally walked well ; extension was 
complete ; flexion to a right angle. The rupture of the external lat- 
eral ligament resulted in the production of a genu varum. 

Treatment. Eeduction, which is usually easy, has been effected by 
traction with coaptative pressure upon the adjoining ends of the femur 
and tibia and flexion of the knee and hip. In some cases flexion 
alone has been sufficient. 

Spence 1 successfully treated an irreducible dislocation by open 
arthrotomy. The patient was a man, sixty years old, who had received 
the dislocation March 15, 1876, two days before admission to the hos- 
pital. After a failure to reduce under anaesthesia, continuous traction 
with a weight of sixteen pounds was made for three days, and then a 
second unsuccessful attempt was made. March 22d, traction with 
pulleys having also failed, the joint was opened by a curved incision 
below the patella; it was found filled with clots, the internal lateral 
ligament broken, and the posterior part of the internal semilunar car- 
tilage displaced. After division of the external lateral ligament and 
the tendons of the hamstring muscles, the dislocation was easily 
reduced. 'The wound was drained and dressed antiseptically, the limb 
placed on a long posterior splint, and continuous traction made with a 
weight of eight pounds. As the lower end of the femur tended to 
project anteriorly, pressure was made upon it in front. The traction 
was maintained until June 15th, and when the patient was last seen, 
September 13th, the limb promised to be very useful. 

In compound dislocations, and in those complicated by injury to the 
main vessels and nerves, the principles of treatment are the same as in 
dislocations forward. 

LATERAL DISLOCATIONS. 

Lateral dislocation, more rare than either of the preceding varieties, 
may be outward or inward, complete or incomplete, simple or com- 
pound. The outward form is more common than the inward. The 
term subluxation has been applied to those cases in which the displace- 
ment is slight. 

1. Outward Dislocations. 

Of the complete form of this dislocation Malgaigne could find only 
one recorded case, and that a doubtful one ; but, since the publication 
of his work, von Pitha 2 has reported two cases in which the disloca- 
tion was nearly, perhaps quite, complete; Hughes 3 has since published 
a third, and McKenzie 4 a fourth. Von Pitha's first patient was a 

1 Spence: Lancet, 1876, vol. ii. p. 534. 

2 Pitha and Billroth : Chirurgie, vol. i\\, part 2. 1>.. p. 258. 
:! Hughes: Lancet, 1880, vol. ii. p. 974. 

4 McKenzie: Canadian Practitioner, January, 1893. 



806 DISLOCATIONS. 

young woman who, while carrying a heavy basket on her back, sud- 
denly doubled up under it. The right tibia was so completely dislo- 
cated outward that its entire upper articular surface stood out free, so 
that von Pitha could easily lay four fingers upon it. The skin was 
tightly and smoothly stretched over the articular surface, and was -con- 
tinuous at a sharp angle with that of the side of the thigh ; the edge 
of the tibia threatened to cut through the tense, thin skin, and in like 
manner the internal condyle of the femur projected abruptly over the 
leg. The patella was displaced outward, and was placed obliquely, 
almost transversely. Reduction was extraordinarily easy. The reac- 
tion was so slight that the patient left the hospital on the next day. . 

His second patient was a robust young man who received his injury 
by springing to the sidewalk from an overturning wagon; the symp- 
toms were similar, reduction easy. Hughes's and McKenzie's cases 
were also similar in appearance and ease of reduction. Hughes's 
patient died promptly; McKenzie's recovered. 

In the incomplete form only a part of the head of the tibia, usually all the 
outer half, projects beyond the side of the external condyle of the femur. 

The commonest cause is outward flexion of the knee, abduction, pro- 
duced by a fall upon the foot or by the pressure of a heavy weight upon 
the posterior, or by a blow upon the outer, side of the knee ; in the lat- 
ter case the blow is probably received upon the lower end of the femur 
and not upon the tibia. A rarer cause is direct violence acting trans- 
versely upon the outer side of the lower end of the femur or the inner 
side of the head of the tibia without causing lateral inflection (Annan- 
dale). The mode of production appears to be rupture of the internal 
lateral and perhaps of the crucial ligaments by abduction of the leg, 
followed by the lateral gliding of the articular surfaces. 

The only reports of direct examination of the injured joint are fur- 
nished by Hargrave 1 and Bonn, quoted by Malgaigne, and by Wells. 2 
Hargrave's patient died on the fifty -third day, after suppuration of the 
joint ; the internal lateral ligament was completely ruptured, the exter- 
nal partly torn ; the anterior crucial torn across, the posterior crucial 
and the ligaments of the patella intact. Bonn's was an old unreduced dis- 
location ; he says all the ligaments were intact and that the external con- 
dyle of the femur rested upon the crest of the tibia. In Well's case a large 
scale of bone was torn from the inner side of the internal condyle ; the 
patient died on the fourth day in consequence of gangrene of the limb. 

In a personal case (1909), Plate LXIV, the rent in the capsule 
extended transversely upward and backward, on the inner side, involv- 
ing the lower portion of the vastus internus and overlying fascia ; 
the internal condyle had passed through the rent (evidently by abduc- 
tion of the leg while the knee was partly flexed) ; and the upper side 
of the rent was tightly lodged in the intercondylar notch. The inter- 
nal lateral ligament was torn away from the femur, and the crucial 
ligaments apparently were torn, certainly in part. After having 
opened the joint by a longitudinal incision along the prominent part 
of the internal condyle I was able, with some difficulty, to lift the 

1 Hargrave : Dublin Quarterly Journal Med. Sci., 1850, vol. ix. p. 473. 

2 Wells : American Journal of the Medical Sciences, 1832, vol. x. p. 25. 



PLATE LXIV 



Fig. 1, 




'ig. 2. 




Outward Dislocation of the Knee. 



DISLOCATIONS OF THE KNEE. 807 

tense engaged portion of the capsule out of the intercondylar notch and 
slip it back over the condyle, reducing the dislocation. 

Instead of being directly outward the displacement may also be 
somewhat backward or forward. When compound, the wound has 
always been on the inside. In one compound case, Notta, 1 the pop- 
liteal artery was ruptured and the patient died after amputation. 

Symptoms. The symptoms are more or less marked in accordance 
with the degree of the displacement; the internal condyle of the femur 
projects more or less markedly on the inner side, and the outer part of 
the head of the tibia on the outer side ; and the greater the displace- 
ment the more likely, according to Malgaigne, is it that the outer part 
of the tibia will be rotated backward. The displacement outward of 
the patella shows corresponding variations in degree ; it may be simply 
inclined, so that its vertical axis is directed downward and outward, 
or it may be carried to the outer side of the external condyle. 

The leg may be flexed or extended, and is usually adducted, but may 
be widely abducted ; voluntary movements are generally impossible. 

Prognosis. The prognosis does not differ materially from that in the 
two preceding forms ; but it is worthy of note that in a case seen six 
years after the accident by Desormeaux (quoted by Spillman) the leg 
was permanently abducted 45 degrees, presumably the consequence of 
failure of repair of the internal lateral ligament. In another, reported 
by Morgan, 2 in which the dislocation had remained unreduced for three 
and a half years, the limb could be flexed to a right angle but could 
not be voluntarily extended, so that the patient fell whenever the leg 
became at all bent while he was standing upon it. 

Treatment. Reduction, generally very easy, is effected by traction 
and direct coaptative pressure upon the ends of the bones. It is very 
important that the limb should be immobilized for a long time after 
reduction in order that the torn ligaments may solidly reunite. Prob- 
ably it would be well to keep the limb for three or four months in a 
firm dressing which would keep it extended and prevent lateral bend- 
ing. Massage and passive motion might be systematically employed 
during much of this time if loss of normal mobility were feared. 

In a case reported by Braun 3 of incomplete outward dislocation 
which proved irreducible arthrotomy was done. The patient was a 
man forty-four years old ; the leg was rotated inward and abducted at 
an angle of 145 degrees ; the internal condyle of the femur was promi- 
nent, and a small movable piece of bone could be felt below its inner 
side. "A curved incision eight centimetres long was made parallel to 
the internal condyle." The small piece of bone proved to be the 
detached internal tuberosity. The rent in the capsule was closely 
filled by the internal condyle ; it was slightly enlarged with the knife, 
and then reduction was easily made. The patient made a slow recov- 
ery ; the joint remained stiff. 

The treatment of compound dislocations and of those in which the 
artery has been torn is the same as in forward dislocations (q. v.). 

1 Notta : Annates M6d. du Calvados, 1S76, quoted by Poinsot. 

2 Morgan : Lancet, 1825-26, vol. ix. p. S43. 

3 Braun : Deutsche med. Wochenschrift, 1SS2, p. 291. 



808 DISLOCATIONS 

2. Inward Dislocations. 

These also may be complete or incomplete, simple or compound. 
Of the complete form there are only two cases on record, Miller and 
Hoffman, 1 and Galli, both quoted by Malgaigne. The first was a 
man twenty-eight years old who while getting into a carriage caught 
his leg between the spokes of the wheel and could not free it before 
the horses started. The femur was completely separated from the tibia 
and projected outward and downward, the external condyle presenting 
through a wound in the skin three inches long. Through this wound 
the joint and the uninjured popliteal artery could be seen. Reduction 
was made at once without difficulty ; recovery. 

Galli's patient, a very muscular young man, was thrown from a 
horse, striking upon the right foot with the limb abducted. The lower 
end of the femur had almost entirely passed through the soft parts on 
the outer side ; the ligamentum patellae was ruptured. Reduction was 
made and the patient recovered. 

The causes of the incomplete form are similar to those of the out- 
ward dislocations : lateral flexion of the knee or a blow upon the outer 
side of the tibia or on the inner side of the condyle of the femur. 

In a case quoted from Cooper by Malgaigne 2 in which there was also 
rotation inward of the tibia, the soft parts covering the external con- 
dyle of the femur behind and externally had been ruptured. The 
limb was amputated, and dissection showed a large rent in the vastus 
externus immediately above its insertion upon the patella ; posteriorly 
the capsule and gastrocnemius were torn ; the lateral and crucial liga- 
ments were intact. 

The symptoms of the incomplete form are the projection of the head 
of the tibia on the inner side and of the external condyle of the femur 
on the outer side. The leg may be inclined outward or inward, rotated 
inward, and more or less flexed. 

Reduction appears always to have been effected without much diffi- 
culty by traction and coaptative pressure ; and the only special feature 
in the prognosis arises from the rupture of the internal lateral ligament, 
for if its repair is not thorough, or if the limb is prematurely used, 
the leg tends to deviate outward (knock-knee) under the weight of the 
body. It would, therefore, be advisable to support the joint for a long 
time by means of a brace. 

ANTERO-LATERAL DISLOCATIONS. 

Antero-lateral dislocations constituted in Malgaigne's classification 
a separate class of very rare occurrence, the tibia being displaced for- 
ward and outward. Of the latter form he found only one recorded 
example and that a doubtful one. In the very rare examples of dis- 
location forward and inward no special features appear ; and the same 
may be said of the equally rare dislocations backward and outward. 
They may, therefore, be treated as belonging to the forward and back- 
ward dislocations respectively. 

1 Miller and Hoffman : London Medical Repository, 1825, p. 346. 

2 Cooper : Quoted by Malgaigne, loc. cit., p. 960. 



DISLOCATIONS OF THE KNEE. 809 



DISLOCATIONS BY ROTATION. 



In this form the dislocation is characterized by a rotation of the leg 
about its longitudinal axis or about a parallel axis passing through the 
centre of one of the condylar surfaces of the tibia ; in the former case 
both condylar surfaces are displaced from their corresponding con- 
dyles, and the dislocation is said to be complete; in the latter only one 
of them is thus displaced, and the dislocation is said to be incomplete. 
The descriptive terms outward and inward are used, as in normal rota- 
tion of the leg, according to the direction in which the toes are turned. 

Outward Rotation. 

The first recorded case is one reported by Dubreuil and Martelliere, 1 
at the time internes in Malgaigne's service. The patient was a woman, 
who while walking in the street was struck upon the back of the leg 
by the end of a ladder carried upon a cart. She was knocked down 
by the blow, her foot caught between the rounds of the ladder, and she 
was dragged a few feet. When brought to the hospital, the leg was com- 
pletely extended and rotated outward, so that the internal tuberosity 
was in front, below the trochlea of the femur, the external tuberosity 
and the head of the fibula behind in the intercondylar notch. The 
patella lay upon the outer side of the external condyle. There was 
also a compound fracture of both bones of the leg in the middle 
third. Reduction was easily made two hours after the accident by 
slight traction upon the upper portion of the leg followed by inward 
rotation. Recovery took place, but the joint was not firm, and nine- 
teen months after the accident the patient could not take a step with- 
out crutches. 

By experiment upon the cadaver the reporters found they could 
produce the dislocation by forcible outward rotation of the leg con- 
tinued until the ligaments were felt to yield. The lateral ligaments 
were then found to be ruptured or torn from one or the other insertion ; 
the capsule, the fascia on the outer side, and some muscular bundles 
were torn, the semilunar cartilages loosened or displaced. The crucial 
ligaments were not torn but lay parallel with each other in the trans- 
verse vertical plane passing through their upper insertions. In one 
experiment the tendon of the biceps was torn away from .the head of 
the fibula. The tendon of the semi-membranosus was wrapped under 
the internal condyle and prevented full extension of the leg. 

Sulzenbacher 2 reported another case and repeated and confirmed 
these experiments. His patient was a young Italian laborer, and the 
dislocation was caused by forcible outward rotation of the leg followed 
by hyperextension of the knee. The leg was extended, neither 
abducted nor adducted, and so far rotated outward that as the patient 
lay on his back the outer border of the foot rested on the bed. Beside 
the rotation there was displacement backward and outward of the 
upper end of the tibia. Notwithstanding the swelling there was a 
distinct projection of the condyles, and the soft parts below them were 

1 Dubreuil and Martellidre: Arch. ggn. de Med., 1S52, vol. xxx. pp. 150 and 288. 

2 Sulzenbacher : Wiener med. Presse. 1880, vol. xxi. p. 272. 



810 DISLOCATIONS. 

deeply depressible. Below the internal condyle was a movable piece 
of bone a.s large as a bean. The upper end of the tibia could be felt 
in the hollow of the knee projecting backward and outward and so 
rotated that the outer surface and the head of the fibula lay furthest 
back and the outer articular surface could be felt through the ^soffc 
parts. The inner articular surface lay in the depths of the popliteal 
fossa, the patella laterally, so that it rested snugly on the outer sur- 
face of the external condyle, its anterior surface being directed outward. 
There was one inch shortening, and the antero-posterior diameter of 
the joint was notably increased. 

Reduction was easily effected by flexing the leg a little, then rotating 
it inward and pressing the head forward, and finally extending. 

There was a tendency during the first fortnight to subluxation back- 
ward and outward ; a gypsum dressing was worn during the second 
fortnight, and on its removal the tendency had ceased. At the end of 
six weeks the patient could walk with a cane. 

The case differs from the preceding one in the additional backward 
and outward displacement of the rotated leg. 

Experimenting on the cadaver, Sulzenbacher found that by rotating 
the leg outward 45 degrees he got an incomplete dislocation, accompa- 
nied by the appearance of a small fragment of bone under the internal 
condyle similar to that observed in his case, and that then by hyper- 
extension he could make the dislocation complete and exactly like that 
of his patient. The lesions found on dissection differed from those 
noted by Dubreuil and Martelliere in this, that the crucial ligaments 
were ruptured and the external lateral ligament untorn. The small 
movable piece of bone proved to be the part of the internal condyle 
to which the internal lateral ligament was attached. 

In a case reported by Boursier 1 still another variety is shown, the 
rotation taking place about the internal condyle as a centre. The 
patient, while standing with the outer side of his right leg resting 
against the cross-bar of a pair of skids by which he was unloading a 
large cask, was overthrown by the rapid descent of the cask which 
struck against the inner side of the right knee. The pain was very 
severe, and when raised by his companions he was unable to stand. 
The knee appeared a little enlarged transversely ; the external condyle 
overlapped the corresponding articular surface of the tibia, forming a 
rather large, hard, rounded prominence. The patella, firmly fixed upon 
this condyle, was placed obliquely, its external border tending to turn 
forward. The relations of the internal condyle and inner surface of 
the tibia were normal. Palpation was painful along the interarticular 
line, especially at the outer side. Voluntary movement was impossible. 
Passively, flexion could be made nearly to a right angle, but was very 
painful ; the limb could not be completely extended, and there was no 
rotation. No sign of fracture. Reduction was easily made under 
anaesthesia by slight traction and inward rotation of the leg. The 
patient recovered completely. 

Another case has been reported by Mazel, 2 and Malgaigne quotes the 

1 Boursier : Journ. de Med. de Bourdeaux, 1882-83, vol. xii. p. 1225, quoted by Poinsot. 
a Mazel : Montpellier Medical, 1863, vol. x. p. 76. 



DISLOCATIONS OF THE KNEE. 811 

accounts of two specimens of old unreduced dislocations given by God- 
man and Petrequin. Of the former it is only said that " the leg lias un- 
dergone complete outward rotation, so that the foot points directly out- 
ward, the heel corresponding to the hollow of the other foot, and the 
articulation of the knee crossing its natural position at right angles/' 
Still another variety, displacement forward of the inner side of the 
head, the outer remaining in place, has been recently reported by 
Henaff. 1 " A sailor, thirty-three years old, while squatting with his 
heels together, thighs abducted, and knees flexed, was struck upon the 
inner side of the head of the left tibia by an iron ring through which 
a hawser had begun to run rapidly. When brought to the hospital 
the leg was partly flexed and not deviated to either side ; flexion and 
extension were limited, abnormal lateral movements very free. The 
relations of the external condyle and tibia were unchanged ; the inner 
side of the head of the tibia Avas displaced forward, and the internal 
condyle was prominent posteriorly. The patella was inclined so that 
its anterior face looked forward and inward, its inner border rested on 
the inner condylar surface of the tibia, and its outer border and point 
raised the skin, the point being nearly in the median line. Reduction 
Avas easily effected by traction and internal rotation, and the patient 
made a complete recovery." 

Inward Rotation. 

Of this the only recorded instance is one reported by Paris, and 
quoted by Malgaigne. " The internal condyle of the tibia had slipped 
behind the corresponding condyle of the femur. The limb was short- 
ened five or six centimetres, and the leg and thigh formed an arc of a 
circle." Malgaigne supposes this to have been an incomplete disloca- 
tion by rotation inward, and explains the alleged shortening as an 
error of observation. He mentions in connection with it a singular 
displacement which he had himself seen, and Avhich he thought 
belonged to this class more than to any other. When seen by him it 
had existed five years. Although the patient limped, he flexed and 
extended the leg quite freely. In extension the internal condyle pro- 
jected very slightly forward and imvard, and the relations of the exter- 
nal condyle Avere normal. In marked flexion the internal condyle 
projected considerably forward and inward, the inward projection 
being more than two centimetres, and the external condyle projected 
slightly forward. 

i Henaff: These de Paris, 1883, No. 277. 



812 . DISL OCA TIOXS. 

DISLOCATION OF THE SEMILUNAR CARTILAGES. 

"Subluxation of the Knee." Hey's "Internal Derangement 

of the Knee." 

A certain group of symptoms at the knee, occasioned usually by 
slight violence, such as the twisting of the leg, or marked flexion of 
the joint, and having a decided tendency to recur, to which attention 
was first permanently called by Hey * nearly one hundred years ago, 
have only of late been clearly connected with displacement of a semi- 
lunar cartilage as the cause. In many cases the symptoms are identical 
with those caused by a floating cartilage in the joint, and many of the 
reported cases, especially the earlier ones, were probably of this char- 
acter. Hey reported five cases, and said he had seen many others ; 
the difficulty always occurred suddenly, sometimes without recognizable 
cause during ordinary use of the limb, the joint becoming "locked" 
in the position of slight flexion, with more or less pain, the patient 
being unable to bring his heel to the ground and walking on the toes, 
but the joint could always be freely moved passively. It was always 
relieved by gradual passive extension of the limb followed by sudden 
full flexion. 

In 1731 Bassius (quoted by Malgaigne) reported the first case, but 
it differs notably from all that have since been reported, for the exter- 
nal semilunar cartilage had become much hypertrophied in conse- 
quence of an arthritis, and formed a projection on the outer side as 
large as the thumb ; it could be pressed into place with crepitus, and 
became displaced when the pressure was removed. 

In some cases a distinct projection had been noticed in front, formed 
by one or the other cartilage, which could be made to disappear by 
pressure or by flexing and extending the joint, and with the disappear- 
ance of the projection the symptoms ceased. It was upon these few 
cases of recognizable projection and upon the sensation sometimes felt 
of a distinct slipping or jar in the joint while it is moved, that the 
theory of displacement of the cartilage rested, it being supposed that it 
slipped forward upon the head of the tibia so that its thicker posterior 
margin lay between the condyle and tibia at or in front of the point 
where they come most nearly into contact or actually touch. 

The only pathological data came from chance examination of a few 
knees without history ; thus in two specimens described by Reid 2 and 
Godlee, 3 the rupture of the attachments had taken place along the 
periphery of the cartilage, and it had lodged vertically in the inter- 
condylar notch alongside the spine of the tibia and the posterior crucial 
ligament. In each the opposing articular cartilage on the condyle and 
tibia showed some roughening. Reid's patient died in the hospital, 
and during his stay there had made no complaint of the knee, and had 
not been observed to limp. 

In another, Fergusson (quoted by Marsh) found in a dissecting- 

1 Hey: Observations in Surgery, Am. ed., 1805, p. 208. 

2 Reid : Edinburgh Medical and Surgical Journal, 1834, vol. xlii. p. 377. 

8 Godlee : Transactions of the Pathological Society of London, 1879-80, vol. xxxi. 
p. 240. 



DISLOCATIONS OF THE KNEE. 813 

room subject " that one of the semilunar cartilages had been torn from 
the tibia throughout its whole length, except at its ends, so that in 
flexion and extension is sometimes slipped behind the articular sur- 
faces. The cartilage was flattened in its outer margin, and when it 
passed behind the condyle of the femur, seemed to fit to the articular 
surfaces as accurately as the internal cavity does in the natural condi- 
tion of the parts." 

Marsh 1 gives a fourth case : " In a subject lately in the dissecting- 
room at St. Bartholomew's Hospital, a considerable piece had become 
partially detached from the rim of the internal cartilage, and was found 
standing up like a tongue, so that it would have had the effect, when 
it was nipped between the bones (as it was in certain positions of the 
joint), of locking the knee. A deep groove on the cartilaginous edge 
of the femur had been formed by long pressure, for its accommodation." 

Since 1881, when Nicoladoni 2 exposing what he thought to be a 
floating cartilage found it was the displaced meniscus, and 1885, when 
Annandale 3 reported four cases diagnosticated as displacement and 
formally treated by arthrotomy, the pathology of the condition has 
been made clear by a number of direct examinations through incisions, 
and very recently Tenney 4 in a most interesting article has given the 
results of examination of 150 joints of cadavers showing the various 
forms of change in the cartilages and fringes. The meniscus most 
frequently displaced is the internal — 45 internal and 17 external in 62 
cases collected by Schlatter. 5 The detachment may be of the anterior 
end or of a variable length of the periphery, or of a piece from the free 
border of the cartilage. The meniscus may be displaced into the inter- 
condyloid notch, or backward into the joint, or slightly forward in front, 
or the detached end may escape forward or backward and to the side. 
Partial detachment of a piece from the upper border seems to be not 
infrequent; one such case is quoted above; Croft 6 reports another; I 
have seen one. 

Symptoms. In most cases the patient feels that the knee has sud- 
denly become locked, with more or less pain and loss of power over 
the limb, which he can neither flex nor extend. Then, after a time, 
and as the result of manipulation of the joint or of the limb, he feels 
that all is right again, and walks as well as before. In others the 
joint has remained stiff and slightly flexed for weeks, or even years 
(Smith's 7 ), and has been cured by pressure with the thumb upon the 
projecting semilunar cartilage, while the joint was repeatedly flexed 
and extended. In some cases the cartilage, usually the internal, can 
be distinctly felt to project in front ; in others it appears to be absent, 
and in others again there is no recognizable change ; usually there is 
pain on pressure at the edge of the tibia beside the ligamentum patella. 

Le Fort, 8 himself the subject of the affection, felt that something 

1 Marsh: Diseases of Joints, p. 199. 

2 Nicoladoni: Arch, fur klin. Chir., 1881-82, vol. xxvii. p. 667. 

:i Annandale : British Medical Journal, 1885, vol. i. p. 779, and 18S7, vol. i. p. 319. 

4 Tenney: Annals of Surgery, July, 1904, p. 1. 

5 Schlatter : Beitrage zur klin. Chir. , vol. xli. part II. 

(i Croft : British Medical Journal, March 19, 188S. 

' Smith : Transactions of the Clinical Society of London, 1SS1, vol. xvii. p. 123. 

s Le Fort : Bull, de la Soc. Chirurgie, 1879, p*. 57S. 



814 



DISLOCATIOSS. 



became displaced forward in the knee whenever the joint was mark- 
edly flexed, and returned to its place with a distinct snap and with pain 
when the limb was straightened. 

In a case seen by Agnew, 1 a lady, while playing with a kitten on the 
floor, suddenly found that both knees had become locked, so that she 
was unable to rise. 

As in these last instances, flexion of the knee beyond a certain point 
is, in some cases, sure to produce the condition, and this is then 
relieved by extension ; but in most the occurrence is not so uniform in 
its mode of production, and the commonest cause appears to be out- 
ward rotation of the leg with slight flexion. 

Treatment. Treatment has almost always yielded good results, both 
in relieving the condition and in preventing recurrence. The manipu- 
lations which have proved most efficient in the common form, those 
due to a twist or turn of the leg, have been the ones recommended by 
Hey, extension as far as is possible without much pain, and then sud- 
den forcible flexion. AVhen the cartilage can be felt to project pressure 
upon it should be conjointly employed. Smith 2 insists upon the neces- 
sity of repeating the reduction daily for several weeks. Jacob 3 says 
the internal meniscus can be reduced with the knee flexed by abducting 
the leg while the patient tries to extend it. 

The after-treatment may require permanent pressure by a pad at the 
point at which the cartilage tends to protrude, or the wearing of a 
brace that will limit the movements of the joint. Marsh, who has 
treated many cases, recommends a clamp (Fig. 354) " which consists 
of a steel band passing across the back of the joint, and ending later- 
ally in two plates, which clasp the joint and skirt the edges of the 

patella, a pad being placed beneath 
Fig. 354. the plate, should either of the semi- 

lunar cartilages be felt to project." 
Prolonged immobilization of the 
limb in a fixed dressing has been 
used in a number of cases and 
seemed to diminish the tendency 
to recurrence. 

Operative measures to effect a 
radical cure have been resorted to 
in a considerable number of cases ; 
the object has been either to remove 
the displaced cartilage or to restore 
it to place and secure it there by 
sutures. The reported results have 
been uniformly good, the removal 
of the meniscus appearing to create no functional difficulty. A longi- 
tudinal incision on the antero-lateral aspect, or a transverse one at the 

1 Agnew : Surgery, vol. ii. p. 114. 

2 Smith : Lancet, June 13, 1891. 

3 Jacob : Brit. Med. Journ., March 7, 1908. 




Clamp to prevent displacement of a semi- 
lunar cartilage. 



DISLOCATIONS OF THE KNEE. 815 

articular line has been employed. Barker 1 in four of six cases found 
the meniscus hidden in the intercondyloid notch, drew it out with a 
hook, sutured it in place, and not a good result, as he did also in the 
other two by fixation. I have always found the anterior portion of the 
internal meniscus displaced inward, sometimes detached at its tip, 
sometimes broken away from the rest, and have removed it. 

CONGENITAL DISLOCATIONS. 

Excluding a few cases in which various malformations of the knee 
have been found in foetal monstrosities showing many other abnormali- 
ties, and one or two doubtful cases, I found (1900) nearly 40 2 reported 
cases of congenital dislocation ; in 22 the dislocation was unilateral, 
backward in 2, forward in 20 with hyperextension of the leg upon the 
thigh, frequently so extreme that the foot lay at the groin. Of the 1 5 
bilateral dislocations 11 were forward, 2 backward, 2 inward ; 6 of the 
cases were stillborn, and many showed other defects of development. 3 

In a few cases there is mention of a blow or fall received by the 
mother while carrying the child, but it cannot be maintained that such 
a cause is in any case clear. The facility with which the displacement 

Fig. 355. 




Congenital dislocation of the knee. 

in the unilateral cases could always be reduced, the normal shape of 
the bones, and the prompt establishment of the functions of the limb 
point toward an accidental mechanical cause ; probably, in the move- 

1 Barker : Lancet, September 18, 1897. 

2 In addition to the bibliography given in the 1st edition, see Joaehimstahl, in 
Berlin, klin. Woch., October 21, 1889, p. 923, 4 cases ; and New York Medical Journal 
March 2, 1889, 6 cases. 

:i See also Musket, Arch, fur klin. Chir., vol. liv. p. S52, who collected 82 cases. o( 
which 7 were real dislocations, 3 contractures in flexion, 72 hvporoxtonsions. 



816 DISLOCA TIONS. 

ments of the foetus the leg is extended and becomes engaged in such a 
position that it cannot be flexed, and then by the pressure of the wall 
of the uterus hyperextension is effected. Hyperextension in conse- 
quence of unopposed contraction of the quadriceps can hardly be 
supposed, for the flexors have not been found paralyzed. In Hamil- 
ton's case of double backward dislocation the flexors were con- 
tracted, and their tendons had to be divided before the legs could be 
straightened. 

In Friedleben's (bilateral) the articular surface of the tibia rested 
against fhe front of the lower end of the femur : the condyles of the 
femur and the head of the tibia were normally developed, the patella 
normally attached, the capsule loose and large. 

In Albert's, a new-born child, both legs were in dorsal flexion at a 
right angle. The articular surface of the femur varied from the nor- 
mal. The upper part of the synovial sac and the ligamentum alare 
were lacking. The inner semilunar cartilage was only a narrow strip, 
the outer one was well developed; the crucial ligaments were very 
broad and long, the inner one being inserted further inward on the 
tibia than normal ; on slight outward rotation of the leg the two crucial 
ligaments became parallel to each other. The popliteal vessels and 
nerves lay behind the external condyle. 

The attitude of the limb at birth, in the forward dislocations, was 
hyperextension to or beyond a right angle, sometimes so extreme that 
the front of the leg was actually in contact with the front of the thigh ; 
usually there was no deviation of the leg to either side. It was always 
freely movable, could be brought down to the position of straight exten- 
sion by moderate force, and in most cases could even be flexed nearly 
or quite as far as usual ; on removal of the pressure the limb resumed 
the position of hyperextension. While the joint was dislocated the 
condyles of the femur projected at the back of the popliteal space, the 
head of the tibia lying against their anterior surface, and the patella 
situated well up on the thigh. In several cases the skin on the front 
of the knee was thrown into transverse folds, in the grooves between 
which sebaceous matter had sometimes collected. Nothing in any case 
indicated that the dislocation was recent and traumatic, and the experi- 
ments made by Hibon upon the bodies of newborn and stillborn chil- 
dren show that in a similar forcible dislocation, even by a force acting 
continuously for several hours, detachment of one or both epiphyses 
always occurred, with, however, but slight separation and not always 
with rupture of the periosteum. In the forcible straightening of the 
leg the quadriceps became tense, and in a few cases this tension pre- 
vented further flexion of the straightened limb. 

The results of' treatment were almost always very good, the limb 
showing a complete restoration of form and function after a few weeks; 
but in two cases the result was not entirely satisfactory. Six weeks 
after birth the leg in Perier's case showed exaggerated extension and 
outward rotation ; the quadriceps was manifestly retracted, and showed 
as a tense cord whenever the attempt was made even slightly to flex 
the leg. In the hope of an ultimate return to the normal condition, 
Gueniot, who then had charge of the case, limited treatment to the 



DISLOCATIONS OF THE KNEE. 817 

maintenance of the extended position and to slight passive flexion and 
traction repeated two or three times daily. In the other case, Maas, 
the limb when first seen was in anterior flexion at a right angle ; 
reduction was easily made, and the limb could then be normally flexed, 
It was placed in a plaster-of-Paris dressing for six weeks, and as the 
tendency to recurrence had not then entirely disappeared the dressing 
was renewed for a time, and afterward a leather knee-cap was worn. 
In its second year the child walked for a time without support, but at 
the time of the report, when it was two and a half years old, there 
was still a tendency to anterior flexion and abduction, and a brace was 
constantly worn. 

SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS. 

These are very frequent at the knee, mainly as the result of chronic 
disease involving the ligaments and the bones of the joint, and of pro- 
longed maintenance of the partly flexed position. There are also 
instances on record of sudden dislocation due to muscular contraction 
during an acute arthritis, and quite a number of the class to which 
Volkmann gave the name deformations-luxationen, or dislocations by 
deformity, those in which the shape of the articular ends of the bones 
has been greatly changed without suppuration, as in arthritis defor- 
mans and Charcot's disease. 

The principal displacements are backward and backward and out- 
ward, usually combined with outward rotation of the leg. As a great 
exception dislocation forward has occasionally been observed. 

Ullman * reports two cases of bilateral subluxation inward gradually 
produced by swinging the body from side to side while at work. 

Examples of dislocation due to the prolonged action of the flexor 
muscles, the knee being long held partly flexed because of disease at 
some point in the thigh, are not very uncommon, and in young people 
its effect is intensified by the exaggerated growth of the femoral con- 
dyles downward by which the lateral ligaments become too short to 
permit the tibia to return to its place. This last-mentioned change 
was first pointed out by Volkmann, in 1874, and deserves to be con- 
stantly borne in mind, for if the attempt is made forcibly to straighten 
such a limb the tibia may turn upon its anterior edge as a centre, so 
that when straightened it is found to lie well behind its proper posi- 
tion, " dislocation by leverage," as it has been termed. 

The dislocations that occur in the course of chronic tubercular or 
other destructive disease must here be passed with simple mention. 

1 Ullman : Centralbl. fur Ckir., August 11, 1894. 
52 



CHAPTEK LV. 

DISLOCATIONS OF THE PATELLA. 

General Considerations — Cause — Outward: Complete, incomplete, vertical- 
Inward — Complete Reversal — Congenital — Habitual or Pathological. 

Dislocations of the patella are rare, less than 1 per cent, of all 
dislocations, according to the tables in Chapter XXVII., and the infre- 
quency with which they have come under the observation of individual 
surgeons and the incompleteness or the obscurity of the reports of 
many cases have combined to make the systematic descriptions rather 
artificial and unsatisfactory. The physical conditions and relations of 
the patella, which is a sesamoid bone developed in the tendon of the 
quadriceps extensor and not an integral part of the joint, are entirely 
different from those of other bones, and the changes in position and 
relations which it undergoes in displacement are very varied. The 
anterior articular surface, or trochlea, of the femur extends higher 
upon the outer than the inner side and presents a central groove 
bounded laterally by a sharp margin from which the internal and 
external surfaces of the inner and outer condyles, respectively, run 
abruptly backward, and the outer condyle projects more sharply for- 
ward than the inner one does. The articular or posterior surface of 
the patella presents a longitudinal ridge nearer its inner than its outer 
margin from which the surface slopes forward to the edge. From each 
lateral border of the bone passes a strong aponeurotic expansion, the 
so-called lateral ligaments of the patella, portions of the fascia lata 
which receive expansions from the vasti muscles and are attached to 
the tibia; of the outer one, the " ilio-tibial ligament" is the strongest 
part and tends to displace the patella outward when the knee is flexed. 
A superficial layer, given off. from the fascia lata on the sides, crosses 
the front of the patella and is separated from it by a bursa. In full 
extension of the knee the patella lies upon the upper part of the 
trochlea of the femur, but it can be drawn almost completely above it 
by the forcible contraction of the quadriceps. This muscle is inserted 
upon the upper border and somewhat on each side of the patella, and 
the long axis of the muscle is inclined to that of the patella and its 
ligament as the shaft of the femur is to that of the tibia — that is, they 
meet at an obtuse angle whose apex is directed inward. As a conse- 
quence of this inclination the traction of the muscle tends to displace 
the bone toward the outer side, and this tendency is resisted by the 
projection of the anterior surface of the outer condyle and by the inter- 
nal lateral ligament of the patella. 

The first collation of recorded cases was made by Malgaigne 1 in 

1 Malgaigne : Gazette Medicale, 1836, p. 433. 
818 



DISLOCATIONS OF THE PATELLA. 819 

1836; the 25 cases which he then collected were increased to 46 in 
1855, when he published his work on dislocations. Streubel l in 1866 
collected 120 cases and made a number of experiments upon the 
cadaver. Elaborate articles were furnished by Panas 2 in 1872 and 
Berger 3 in 1877, but the most original and at the same time the most 
recent one is the paper by von Meyer/ Professor of Anatomy at 
Zurich. 

The patella may be displaced to different distances on the outer or 
the inner side while the knee is extended or partly flexed, and with 
such displacement may be combined varying degrees of rotation about 
its own longitudinal axis. These combinations are so numerous and 
varied that if a classification should be made according to them it 
would confuse rather than simplify their study and description. As 
some of the most striking differences depend upon the rotation of the 
patella upon its vertical axis, it will perhaps simplify the subject first 
to consider the conditions which determine the fixation of the displaced 
bone, and in doing this I shall speak only of displacements to the outer 
side. 

The bone may be displaced to the outer side by muscular action or 
by a force acting upon its inner lateral border ; as it passes sideways 
along the projecting surface of the condyle its outer border is raised 
and its inner border depressed into the bottom of the trochlear groove ; 
if the force continues to act the patella is carried past the edge of the 
trochlea to the outer side of the external condyle, and when its longi- 
tudinal ridge passes this edge the outer border of the patella may be 
turned backward by the traction of its outer lateral attachments and 
the bone comes to rest with its articular surface against the outer side 
of the condyle, and its anterior surface looking outward ; or it may 
undergo no rotation, and may come to rest with its inner border against 
the outer surface of the condyle, its anterior surface looking more or 
less directly forward, and its outer border projecting markedly out- 
ward ; or, again, it may undergo rotation in the opposite direction and 
come to rest with its inner border directed backward, its anterior sur- 
face looking inward against the outer surface of the condyle, and its 
outer border directed forward. These three forms constitute the 
" complete outward dislocations." 

If the force is not sufficient to carry the patella entirely past the 
outer edge of the trochlea, the bone may come to rest with its inner 
border in the bottom of the trochlear groove, its posterior surface rest- 
ing partly against the outer surface of the trochlea and partly project- 
ing beyond it, its outer border directed forward and outward, and its 
anterior surface looking forward and inward — the "incomplete out- 
ward;" or the rotation may be somewhat greater, and while the inner 
border still rests in the groove of the trochlea the outer border looks 
directly forward, and the anterior surface directly inward — " vertical " 
or " edgewise " dislocation ; or the rotation may be still greater, the 
anterior surface being turned so as to look directly backward and lie 

1 Streubel : Schmidt's Jahrbucher, 1866, vol. exxix. p. 311. and vol. cxxx. p. 54. 

2 Panas: Diet, de Med. et Chir. pratiques, vol. xvi. p. 40. art. Genou. 

3 Berger: Diet. Eneyclop. des Se. Med., 3d series, vol. v. p. 334. art. Rotule, 

4 Von Meyer: Arch, fur klin. Chirurgie, 1882 3, vol. xxviii. p. 0.">t> 




820 DISLOCATIONS. 

upon the front of the trochlea, and the posterior surface looking 
directly forward under the skin — " complete reversal/' 

It appears, then, that the bone frequently becomes fixed, and firmly 
fixed, in positions of apparently great instability — that is, resting upon 
the front or side of the femur only by its narrow lateral edge, and. the 
fixation which is given to it in these positions is given by the tension 

of the soft parts attached to it and by the 
FlG - 356 - overlying fascia. It may be compared to 

5 6 a stick on end under a tightly stretched 

.\'\ f\ ,*. sheet, w 7 hich will stand not only upright, 

•\ Ci*v*- y I but a ^ so wnen inclined, so long as its 

lower end does not slip along the ground, 
or its upper along the sheet. 
'•f.->y ^\ It also appears, in consequence, that the 

bone may take many intermediate posi- 
tions between the extremes, and that con- 
sequently the grouping of the different 
positions must be somewhat arbitrary. 
The terms in general use are complete and 
incomplete outward and inward disloca- 
disiocations of the patella. tions, edgewise or vertical (outward and 

inward) dislocations, and complete reversal 
in either of the two directions. Another form, dislocation downward 
into the intercondyloid notch or between the external condyle and the 
head of the tibia, with some rotation about the transverse axis in either 
direction, has been observed several times in the last few years. I 
have termed it downward with rotation about the transverse axis. The 
terms cuneen, cuneata, and einklemmung have been used to indicate the 
fixation of the patella like a wedge. Simple displacements upward or 
downward, the result of rupture of the ligamentum patellae or of the 
quadriceps, do not, I think, deserve to be deemed dislocations ; the 
bone is not fixed in its new position, and the displacement is only an 
incident of another and controlling lesion. Among the incomplete out- 
ward and inward dislocations those in which one edge of the patella is 
turned sharply forward differ from the corresponding edgewise ones only 
in the degree of rotation, and the distinction between them is not only 
difficult to make in practice, but also does not seem worth preserving. 
I shall, therefore, group them all as edgewise dislocations, and limit 
the term incomplete to others in which the rotation is absent or slight. 
The outward dislocations are much the more common ; it is doubtful 
if any really complete inward dislocation has been recorded, and of 
Malgaigne's 46 cases only 6 were incomplete inward. Of the vertical 
or edgewise dislocations the outward appear to be somewhat more 
frequent than the inward. 

Cause. The cause and mode of production of the different forms 
are, in many respects, the same. The dislocation may be produced 
either by muscular action, contraction of the quadriceps, or by external 
violence acting directly upon the patella. Of the former there are 
many unquestionable examples ; a man dislocates the patella while 
fencing, a woman by jumping backward and to one side, a boy by 



DISLOCATIONS OF THE PATELLA. 



821 



jumping upward and turning partly around to strike a ball. Of the 
latter, external violence acting directly upon the patella, the com- 
mon examples are falls and blows upon the knee ; in several instances 
a man riding a horse has struck his knee violently against another 
moving in the opposite direction. In a number of cases it has been 
noted that the knee was previously affected with hydrarthrosis, and in 
a few genu valgum existed. In the cases of frequent, or habitual, dis- 
location some such predisposing cause is supposed always to exist. 

OUTWARD DISLOCATIONS. 



Ftg. 357. 



1. Complete. 

In complete outward dislocations the patella is displaced entirely to 
the outer side of the external condyle, against which it rests either by 
its posterior, cartilaginous surface, or, more rarely, by its inner border, 
its anterior surface being still directed forward, or by the inner part 
of its anterior surface, the outer border projecting forward and the 
anterior surface looking inward. 

According to von Meyer, and his opinion is based upon clinical 
observations, as well as upon anatomical and experimental data, the 
patella can reach this position either by passing outward at or above 
the upper part of the trochlea in complete extension or hyperextension 
of the knee, or by passing outward and upward over the lower border 
of the condyle while the knee is flexed 
nearly to a right angle. In the former case 
the dislocation may be produced by muscular 
action, the contraction of the quadriceps ex- 
tensor, by which the patella is raised so high 
that its passage is no longer resisted by the 
outer border of the trochlea. Hyperextension 
of the knee favors the displacement by carry- 
ing the patella still higher above the trochlea. 
Other conditions that favor the displace- 
ment are exaggerated outward rotation of 
the leg and bending inward of the knee. 
As illustrative examples Meyer quotes cases 
reported by Foucart and Robert. A mus- 
cular young man jumping down from a 
stool (apparently backward) felt a sharp 
pain, and found he could no longer stand 
on the right foot ; examination showed an 
outward dislocation of the patella. A 
woman, carrying a heavy burden upstairs, 
felt a sharp pain and a cracking in the right 
knee, and was unable to walk ; the patella was dislocated outward. 

External violence can produce the dislocation at the same, upper, point. 

In either case the further displacement of the patella downward 
upon the outer surface of the condyle and its fixation there are aided 
by the subsequent flexion of the knee which involuntarily follows 
upon the sensation of an injury received there. 




Complete disloeation of the 
patella outward. (ANGER.) 



822 DISLOCA TION& 

In studying the manner in which displacement took place, by exter- 
nal violence, while the knee was partly flexed, von Meyer found that 
the resistance of the ligamentum patellae compelled the bone to move 
in a curve downward and outward, so that it lodged over the lower 
part of the condyle, or even in the groove between it and the tibia, and 
the tendon of the quadriceps slipped sidewise over the edge of the 
trochlea, and lay upon the outer surface of the condyle. 

Pathology. The pathology of the commoner form has been studied 
only in experiments upon the cadaver and in specimens of old unre- 
duced dislocations, of which seven cases have been reported. In four 
of these seven cases the internal lateral ligament of the patella was 
torn, and in one the rent extended upward in the vastus internus more 
than three inches above the patella. Experiments upon the cadaver 
confirm these facts. It may be added that in three cases of long stand- 
ing the bones had undergone various changes ; in some the patella was 
hypertrophied, in others atrophied ; in some it had lost part or all of 
its articular cartilage ; in some the leg was distinctly rotated outward, 
presumably the result of the traction exerted upon it through the 
ligamentum patellae. 

The only examinations of uncomplicated recent cases of which I 
have knowledge are one reported by Andrews x and one in which I did 
an arthrotomy to effect reduction. Andrews's specimen was obtained 
by amputation, which was rendered necessary by a compound fracture 
of the leg. The displacement was of the rare form in which the 
patella has undergone no deviation about its longitudinal axis and 
rests against the external condyle only by its inner border (Fig. 358). 
The patient had been run over by a freight car. 
Fig. 358. " The patella was found shoved nearly straight out- 

ward with its inner edge resting firmly against the 
outer condyle, and with its front and back surfaces 
presenting in a nearly normal direction. ... At the 
place where the inner border of the patella rested 
against the femur the shell and spongy tissue of the 
condyle were crushed in, making an oval or spoon- 
shaped hollow about one inch long and five-eighths 
inch wide. The sharp inner edge of the patella rested 
firmly in this hollow and was thus effectually pre- 
vented from slipping. The rest of the patella was 
stoutly held in position, like a tent-pole or derrick, 
by tight bands drawing in three different directions, 
Andrews's case ag f n ows . 1. By a portion of the vastus externus 

of dislocation of , , . \ r , , , . -. -* 

the patella out- muscle drawing the outer angle upward, inward, and 
ward. backward. 2. By a part of the rectus femoris, not 

represented in the figure, but drawing upward, inward, 
and forward. 3. By the ligamentum patellae, drawing downward and 
inward. 

" The vastus internus was torn off. The inner half of the rectus 
was torn off with the vastus internus, and the lateral attachments of 
the capsular ligaments to the sides of the patella were effectually ripped 
away, but the outer part of the rectus was still attached." 

1 Andrews : Annals of Anatomy and Surgery, 1883, vol. vii. p. 199. 




DISLOCATIONS OF THE PATELLA. 



823 



Fig. 359. 



My patient was a well-grown lad sixteen years old who fell while coast- 
ing on skis, his Hexed knee striking against a rail. The patella stood 
out from the side, as in Andrews's case, but the physician who sought 
to reduce it gave it a half turn, so that when I saw him its outer border 
projected forward well above the level of the condyle, the knee being 
in straight extension. I opened the joint widely in front and found 
the internal expansion widely torn and the vastus internus detached 
from the patella. Both condyles projected through the rent, and the lig- 
amentum patella? was engaged beneath and behind the edge of the outer 
condyle, effectually preventing reduction until after it had been pried 
out of its position with an elevator. The patient made a good recovery. 

Symptoms. The symptoms are loss of power to stand upon the limb 
or actively to move the knee, pain, and deformity. The knee is usually 
partly flexed, but occasionally has been found fully extended. Passive 
motion is painful, complete extension usually possible, further flexion 
rarely possible. 

The knee appears broadened and flattened anteriorly ; the normal 
prominence of the patella is lost, and in its place is a depression through 
which the anterior articular surface of the condyles can be distinctly 
traced unless the swelling is too great. The patella can be readily felt 
upon the outer side of the condyle, and the tendon of the quadriceps 
and the ligamentum patella? show T as tense 
bands under the skin. Usually the patella 
rests with its articular surface against the 
outer surface of the condyle and its inner 
border directed forward, but, as has been 
already said, it may stand directly out from 
the condyle, resting against it by its inner 
border only, or it may be rotated in the op- 
posite direction so that its outer border is 
directly in front. 

Treatment. The method of treatment that 
has proved the most successful is one pro- 
posed more than a hundred years ago by 
Valentin, which consists in full extension 
of the knee and flexion of the hip to relax 
the quadriceps, followed by direct pressure 
with the hands upon the patella ; it may be 
necessary to increase the laxity of the ten- 
don of the quadriceps by pressing the lower 
part of the muscle downward toward the 
knee. Possibly a device which Duplay em- 
ployed successfully in a vertical dislocation 
might be used, if pressure with the hands 
failed ; he inserted the points of a strong 
double hook through the skin, engaged them under the edge or in the 
anterior surface of the patella, and drew the bone forward. When the 
ligamentum patella? is engaged behind the condyle, as in my case, 
reduction without arthrotomy is impossible. 

In cases that have remained unreduced the usefulness o( the limb 




Dislocation of the patella out- 
ward. (Duplay.) 



824 DISLOCATIONS. 

has sometimes been 'well restored, the patients being able to walk freely 
and troubled only in making complete extension. In other eases, again, 
the disability has been great, the knee being stiff and the patient able 
to walk only with crutches. Occasionally the accident is followed by 
a marked tendency to recurrence on flexion of the knee. 

2. Incomplete. 

The cases to which I limit this group are those in which the dislo- 
cation takes place while the knee is extended, and in which the patella 
rests above and partly to the outside of the outer part of the femoral 
trochlea, its apex being probably still on the median side of the crest. 
It is to be remembered that in most systematic descriptions the group 
is made also to include cases of moderate edgewise or vertical displace- 
ment, those in which the inner border of the patella rests in the hollow 
of the trochlea and the outer border projects outward and forward ; 
but still the majority of the reported cases are of the kind to which I 
have restricted the use of the term. There are, however, cases of 
habitual dislocation in which the patella moves outward during flexion 
of the knee and the outer border turns backward, which might properly 
be termed incomplete. Malgaigne l reports one such in which the con- 
dition followed a primary traumatic dislocation, and a number have 
been reported in which the condition developed gradually or was 
thought to have existed at birth. 

The causes are essentially the same as those which produce the com- 
plete outward dislocations in which the patella escapes at or above the 
upper part of the trochlea, that is, muscular action and external vio- 
lence received while the knee is fully extended or even hyperextended. 

Von Meyer finds the explanation of the incompleteness of the dis- 
location in the supposition that the lateral movement of the patella 
takes place while it is still at a lower point upon the femur than it is 
when it undergoes displacement outward ; the outer margin of the 
trochlea engages in the sulcus at the junction of the patella and liga- 
mentum patella?, and thus the bone is prevented from being drawn 
further outward by the traction of the ilio-tibial band. 

Direct examination has been reported in only one case, and that an 
old one, Diday ; 2 the specimen came from a man thirty-four years old ; 
the deformed patella rested on the external condyle and was prevented 
from moving inward by a bony ridge which occupied the trochlea ; the 
articular surface extended an inch higher upon the outer than upon 
the inner condyle. The patient walked without difficulty. 

The limb is in extension, and any attempt to flex is painful. The 
inner half of the trochlea can be distinctly traced with the finger, and 
the patella can be recognized above and to the outer side of its normal 
position, with its anterior surface looking almost directly forward, and 
if inclined at all it appears to be usually inclined outward. 

The treatment is the same as that of the complete form : flexion of 
the hip and extension of the knee to relax the quadriceps, followed by 
direct pressure inward upon the patella. Reduction is easy and some- 
times spontaneous. 

1 Malgaigne : Loc. cit... p. 912. 2 Diday: Bull, de la Societe Anatomique. 1836. p. 297. 



DISLOCATIONS OF THE PATELLA. 825 

3. Outward Edgewise or Vertical Dislocations. 

According to Malgaigne this form of dislocation was first reported 
in 1777 byJNannoni, an Italian surgeon, who communicated two cases 
to the Academie royale de Chirurgie. The subject was not again men-, 
tioned until Malgaigne, in 1836, gave a description of it. Since that 
time a considerable number of cases have been reported ; without mak- 
ing a very thorough search I found about thirty, five of which were 
reported in the New York Medical Record between the years 1873 and 
1879, and in this enumeration I have not included cases reported as 
incomplete outward dislocations, although I include such in the class- 
ification. 

The dislocation is characterized by a displacement outward of the 
patella and its rotation upon its longitudinal axis, by which its inner 
border is brought to rest at or near the bottom of the groove of the 
trochlea, while the outer border projects more or less directly forward 
and its anterior surface looks inward ; it is said by Panas that its apex 
is also directed slightly backward. 

Muscular action is the most frequent cause, and in some cases the 
contraction of the muscle appears not to have been forcible, as in 
Martin's 1 patient, a young girl, who caused the dislocation by moving 
in bed ; in others more force has been exerted, as a boy in throwing a 
snowball, a man in wrestling, another in stumbling, another in jump- 
ing. External violence is a less frequent cause ; a blow upon the inner 
edge of the patella by which the bone is pushed outward, its inner 
border depressed into the hollow of the trochlea, and its outer border 
raised by the passage of the bone along the slope of the external con- 
dyle. The mode of production by muscular action has not been made 
clear. 

The patella may rest partly against the projecting outer portion of 
the trochlea, or it may touch the femur only by its inner edge even 
w T hen its outer border still lies somewhat to the outer side of a sagittal 
plane passing through the inner one, and in one case, Payen, quoted 
by Malgaigne, the patella had turned more than 90 degrees, so that its 
outer border lay a little to the inner side of the inner border. Its 
fixation in this position without lateral support must be attributed to 
the tension of the overlying soft parts and the untorn parts of the 
capsule, for in one case in which both the tendon of the quadriceps 
and the ligamentum patellae were cut subcutaneously by the surgeon 
in the effort to reduce, the bone remained as firmly fixed as before. 

The knee is generally extended, but in some cases it was flexed half 
way to a right angle, and is usually immovable because of pain. The 
deformity is characterized by the sharp projection of the outer border 
of the patella in front, on each side of which the skin is depressed so 
that the anterior and articular surfaces of the patella can be felt, but 
sometimes the skin is stretched tightly toward each side. 

The most successful treatment has been that recommended for the 
preceding forms : flexion of the hip, extension of the knee, and pressure 
upon the patella, the latter being so directed as to force the projecting 

1 Martin : Arch. gen. do Mod., 1831, vol. xxvi. p. 259. 



826 DISLOCATIONS. 

outer border outward and backward, but this has failed in several cases 
in which reduction was afterward obtained by forced flexion of the leg 
or, in one case, by getting the patient forcibly to contract the quadriceps 
and then pressing upon the patella after it had been thus drawn upward. 
Possibly Duplay's device, above mentioned, of drawing the patella for- 
ward with a strong sharp hook, would be of use by diminishing the 
friction between it and the femur. Eben Watson, and others following 
his example, succeeded by slightly flexing the leg upon the thigh during 
anaesthesia, pressing the patella moderately outward, and then suddenly 
extending the leg. Three surgeons have resorted to section of the liga- 
mentum patellae, and one of them also to that of the tendon of the 
quadriceps, but without success, and in the last one the joint suppu- 
rated and the patient died. 

INWARD DISLOCATIONS. 

These are so similar to the outward dislocations in their nature, 
causes, symptoms, and treatment that a detailed description is unnec- 
essary. 

Complete Inward. 

This dislocation is denied by several authors, the only alleged cases 
being those of Putegnat and Walther, both quoted by Malgaigne. The 
former was traumatic in origin, but when the patient came under 
observation the condition was that of habitual dislocation : the patient, 
a girl thirteen and a half years old, had fallen upon her knees five 
years before, and since that time both patella? had been so freely mov- 
able that she sometimes amused herself by dislocating and reducing 
them more than a hundred times in an hour. The right patella could 
be more easily dislocated outward, the left one inward ; but both could 
be dislocated so completely inward that their anterior surfaces were 
exactly in contact when the knees were brought together. The liga- 
ments were so relaxed that the legs could not be completely extended 
by the contraction of the quadriceps. 

Of Walther's case, nothing is known but a brief description in 
Latin of a specimen in a museum at Berlin. Malgaigne thought it 
might be a complete inward dislocation, but admits that its character 
is uncertain. 

Incomplete Inward. 

Of incomplete inward dislocation only one case has been reported, by 
Key 1 ; it also w y as quoted by Malgaigne. The patient, a girl twenty 
years old, slipped and fell ; she felt great pain in the left knee, and 
was unable to walk. " The patella was found resting on the inner 
condyle, the outer part of its articulating surface being supported 
obliquely by the projecting edge of the trochlea of the femur. Gentle 
pressure on the inner edge of the patella, as the limb lay on the bed, 
reduced it to its natural position." The joint suppurated, and appar- 
ently the patient died or the limb was amputated. The tendon of the 
vastus externus was partly torn through. 

1 Key : Guy's Hospital Reports, 1836, vol. i. p. 260. 



DISLOCATIONS OF THI? PATELLA. 827 

Inward Edgewise or Vertical Dislocation. 

This seems to be nearly as frequent as the corresponding outward 
form. Possibly its relative frequency and the rarity or absence of the 
complete and incomplete inward forms are to be explained by the 
greater projection inward of the internal condyle, and the relative 
shortness of the ligamentum patellae, which prevents the patella from 
reaching that side of the condyle. 

COMPLETE REVERSAL. 

Complete reversal, the outer border passing in front to the inner side, 
so that the anterior surface rests against the trochlea and the articular 
surface is directed forward, has been reported in only two cases, which 
are briefly quoted by Malgaigne as follows: "In 1752 J. Sue saw a 
dislocation produced by muscular action in which he clearly recog- 
nized a two-thirds reversal of the patella from without inward without 
any evidence of rupture of the ligaments. Subsequently Hevin said 
that he had heard Bruyeres read before the Academie royal de Chir- 
urgie the details of a total reversal of the patella upside down, also 
without rupture of the ligaments ; in the latter case the cause was a 
blow received upon the inner part of the knee." 

Complete reversal, the inner border passing in front to the outer 
side, has been reported in three cases, Castara, quoted by Malgaigne, 
Wragg, 1 and Gaulke. 2 

Castara's patient, a girl seventeen years old, bent forward to lift a 
book from a table, resting her weight upon the extended right leg, and 
pressing the outer border of the patella against the edge of a chair ; 
she suddenly cried out, and Castara, summoned immediately, found 
the leg partly flexed, and could extend it but very little. The patella 
rested by its outer border upon the outer and upper part of the trochlea 
of the femur, which it covered only over a breadth of a quarter of an 
inch ; its inner border inclined outward and projected in this direction 
two and a half centimetres, its articular surface looking forward and 
inward. The tendon of the quadriceps and the ligamentum patellae 
each formed a quite thick and hard rounded cord above and below. 
The surgeon grasped the bone with his thumbs and forefingers, and by 
a simple movement of rotation from behind forward, and from without 
inward, restored it easily to its place. 

Wragg' s patient was a negro, who had been struck upon the outer 
side of the right patella. The limb was extended and immovable. 
The inner border of the patella had turned forward and outward, and 
lay about half an inch to the outside of the normal position of the 
outer border; the outer border could be felt deep in the trochlea about 
half an inch from its inner edge. The tendon of the quadriceps and 
the ligamentum patellae showed under the skin as hard twisted cords : 
very little passive motion at the knee. The dislocation was reduced 

1 Wragg: Charleston Medical Journal, May, 1856, abstract in Schmidt's .lahrbueher. 
1856, vol. xci. p. 362. 

2 Gaulke : Deutsche Klinik, 1863, p. 108. 



828 DISLOCATIONS. 

easily by pressing with the thumbs against the projecting border, and 
with the index- and middle fingers against the outer border in the 
opposite direction. The reaction was slight, and the patient made a 
good recovery. 

Gaulke's patient, a girl seventeen years old, injured her knee, in a 
fall from a horse, and was not' seen by him until ten days after the 
accident. " The patella lay entirely upon the outer condyle of the 
femur, and had been so turned about its longitudinal axis that its pos- 
terior surface looked forward and inward, and the anterior surface 
backward and outward." After several failures he reduced by making 
pressure against the projecting inner border with one jaw of a vise, 
such as is used by carpenters to hold pieces of wood that have been 
freshly glued together, the counter-pressure being made with the other 
jaw against the internal condyle. The force of the screw was so 
applied as to press the inner border of the patella forward and inward, 
while its outer border was expected to move along the outer slope of 
the trochlea. After many efforts, the patella suddenly moved with a 
snap, turned about its long axis, and fell back into place. The patient 
recovered in a fortnight. 

Downward with Rotation About Transverse Axis. 

In this the patella is displaced downward and lodged between the 
femur and tibia with some rotation about its transverse axis in one 
direction or the other. Eight cases 1 have been reported. In all the 
cause was external violence acting on the knee, probably while flexed, 
and in two cases causing also a subluxation of the knee. 

The slightest form is represented by Newman's case. A fall upon the 
knee ; " the lower border of the patella was wedged in between the 
head of the tibia and the condyles of the femur, . . . and the tendon 
of the quadriceps extensor muscle was thrown forward." The dislo- 
cation was easily reduced. It is the only case of the kind. 

In 5 cases (Midelfart, Deaderick, Schmidt, Rutherford, Cheesman) 
the upper border was turned backward into the cleft between the femur 
and tibia and the quadriceps was torn away from it. In all but one 
the position was determined by inspection after incision ; in Deader- 
ick's it was probably turned the same way. Deaderick reduced by 
manipulation after many efforts ; he thinks binding tissues were torn 
in the course of the unsuccessful attempts and that this made the 
reduction possible at last by a manipulation which had previously 
failed many times. In most of the others considerable force was 
needed to dislodge the bone after it had been exposed. This was 
attributed by some to the tension of the ligamentum patellae, but I 
should think that engagement of the torn edge of the lateral expan- 
sions on the side of the condyles was at least a contributing cause. All 
these patients made good recovery. 

In 2 cases (Szumann, Kiittner) the patella lay between the outer 

1 Midelfart, Ctlblatt fur Chir., 1888, p. 56: Szuman, Beilage zum Ctlblatt fur Chir., 
18S9. No. 29, p. 101; Deaderick, Annals of Surg., vol. xi. p. 102; Schmidt. Ctlblatt far 
Chir.. 1900, p. 1023 . Newman and Rutherford. Lancet, June 22, 1901. p. 1761 ; Kiittner. 
Beitrage zurklin. Chir., vol. xlii. p. 553 ; Cheesman, Annals of Surg., vol. xli. p. 108. 



DISLOCATIONS OF THE PATELLA. 829 

condyle of the femur and the tibia, its articular surface against the 
femur in Szumann's, against the tibia in Kiittner's, and the quadriceps 
was tightly stretched across the outer side of the condyle, the end of 
the femur projecting through a large rent in the internal lateral expan- 
sion. The external lateral ligament was torn in Kiittner's, both lateral 
ligaments in Szumann's, and the crucial ligaments in both. In Kiitt- 
ner's the skin was torn and he amputated. Szumann reduced with 
difficulty after having opened the joint and divided the ligamentum 
patellae. It seems probable that in both cases the dislocation was first 
to the outer side, while the knee was flexed, and that then forced 
adduction of the leg tore the lateral and crucial ligaments and opened 
a gap into which the patella was drawn. In both cases the violence 
was great and repeated ; in Szumann's the leg was caught in machinery, 
in Kiittner's in a wagon wheel. Szumann's made a good recovery. 
For Lannelongue's and Potel's cases see the next two sections. 

CONGENITAL DISLOCATIONS. 

In a number of reported cases the term congenital has been used 
although the writers knew that the dislocation had first appeared long 
after birth ; in most of the others it has not been possible to ascertain 
with certainty the date of the appearance of the condition, and in many 
the probability is very great that it had been gradually developed long 
after birth. The reported cases in which it is reasonably certain that 
the condition existed at birth are not numerous, perhaps fifteen or 
twenty, but if to these are added the other cases which several of the 
patients have said existed in other members of their families, the num- 
ber becomes considerably increased. The principal paper upon the 
subject is one by Zielewicz 1 ; Bessel-Hagen 2 read one before the Ber- 
lin Medical Society, and presented 2 cases, but the published abstract 
is very short. Zielewicz's paper gives the details of 13 cases, in 3 of 
which the patella was dislocated upward with elongation of its liga- 
ment ; in the remaining 10 the dislocation was outward. The con- 
genital character of the first 3 is uncertain. Of the outward ones in 
which the sex is noted, 6 were males, 3 females ; in 5 both patellae were 
dislocated, and in all the patients were able to make good use of the 
limb. 

Lannelongue 3 reported the case of a boy twelve years of age in whom 
since birth the very small patella disappeared, on semi-flexion of the 
joint, into the space between the femur and the tibia so that only its 
apex could be felt. The ligamentum patella? was only one centimetre 
long. It has been grouped with those of the preceding section, but I 
do not think it should be termed a dislocation. 

Bessel-Hagen points out that the cases may be grouped in three 
classes: 1. The incomplete, in which the patella lies upon the outer 
condyle when the knee is extended, and returns to its normal place 
when the knee is flexed; 2, complete intermittent, in which the displace- 

1 Zielewicz: Berlin, klin. Wochenschriffc, 1869, vol. vi. p. 25. 
- B^ssel-Hagen : Deutsche nied. Woehensehri ft. 1881, p. 45. 
3 Lannelongue : Bulletin Medical, 1895, p. 894. 



830 DISLOCATIONS. 

ment occurs during flexion ; 3, complete permanent, in which the dis- 
placement is increased during flexion, and is not overcome during 
extension. 

Caswell 1 reported a case of congenital dislocation of both patellae in 
a man, forty-three years old, who said that five members of his family, 
in three generations, had the same deformity — his father, sister, son, 
and nephew. Dr. Caswell examined the son and confirmed the state- 
ment to that extent. 

Shapleigh 2 saw a man, thirty-nine years old, both of whose patella? 
" were dislocated outward, resting on the upper and outer surface of 
the external condyle of the femur." They were of normal size. The 
patient said the condition had existed from birth, and that his grand- 
father, father, and one of his own children, four generations, had the 
same deformity. The man walked without difficulty and had served 
as a soldier during the war. 

An anonymous writer 3 reported a case of congenital dislocation of 
both patellae in a girl whose father, aunt, and aunt's daughter were in 
the same condition. 

HABITUAL OR PATHOLOGICAL DISLOCATIONS. 4 

A number of varying conditions in the bones or ligaments of the 
knee may have for consequence the frequent, even habitual, dislocation 
of the patella in certain positions or movements. Almost without 
exception, these dislocations are to the outer side and complete. Many 
cases reported as congenital are probably of this character ; Isemeyer, 5 
indeed, published an elaborate paper on the subject in which he claimed 
that all reported cases of congenital dislocation were really pathological 
ones. 

Among the alleged causes are relaxation of the ligaments, chronic 
arthritis of different kinds, malformations of the knee, especially genu 
valgum, and injury of the lower part of the vastus internus. 

In genu valgum the increased abduction of the leg upon the thigh 
produces a corresponding exaggeration of the angle between the quad- 
riceps and the ligamentum patella? in consequence of which the con- 
traction of the muscle constantly tends to draw the patella outward, 
and if the patella passes to the outer side of the outer condyle the 
muscle then aids still further to abduct the leg and increase its devia- 
tion. Indeed, in some of the reported cases it has remained in doubt 
whether the abduction of the leg preceded or was itself the conse- 
quence of the dislocation of the patella. 

Condamin 6 reported a case in which persistent outward displacement 
took place gradually in consequence of operative division of the lower 
portion of the vastus internus in the treatment of an osteomyelitic 
abscess. 

1 Caswell : American Journal of the Medical Sciences, July, 1865. 

2 Shapleigh : Boston Medical and Surgical Journal, 1881, vol, cv. p. 252. 

3 New York Medical Journal, 1885, vol. xlii. p. 27. 

* For a full discussion, 95 cases, see Delia Vedova, Arch, de Ortopedia, 1902. 

5 Isemeyer: Arch, fur klin. Chirurgie, 1866, vol. viii. p. 1. 

6 Condamin : Lyon Med., September 30, 18S8. 



DISLOCATIONS OF THE PATELLA. 831 

The patella is habitually very movable, and the dislocation takes 
place or is increased during flexion of the knee and is reduced or 
diminished during extension. The functions of the limb are more or 
less interfered with, complete voluntary extension being difficult or 
impossible. The femur tends to rotate inward, and the leg outward 
and to become abducted. 

Potel l saw a boy fifteen years old with hip disease and an acquired 
genu recurvatum whose patella disappeared on semi-flexion as in Lan- 
nelongue's case quoted in the preceding section. The ligamentum 
patellae was very short. Its right to be deemed a dislocation is open 
to the same objection. 

A case which resembles Putegnat's of complete inward dislocation 
in the facility with which the patient could rapidly produce and reduce 
the dislocation by muscular action is reported by Albert ; 2 the patient 
was a boy, sixteen years old, with genu valgum on the affected side. 
When the knee was held at an angle of 160 degrees he could repeat 
the production and reduction with great rapidity and ease. Flexion 
at 150 degrees was the limit at which voluntary reduction could be 
made ; voluntary dislocation was possible even when flexion was carried 
to 90 degrees. 

The treatment consists in the wearing of a knee-cap designed to 
oppose the displacement during flexion or to restrict the flexion to the 
range beyond which the displacement took place. 

Roux 3 relieved a case of habitual dislocation outward following 
rupture of the aponeurosis on the inner side by dividing the vastus 
externus, suturing the rent on the inner side, and displacing the inser- 
tion of the ligamentum patellse upon the tibia half an inch inward. 
Bradford 4 did the same with success. 

Another French surgeon (I have mislaid the reference) relieved the 
condition by narrowing the internal lateral expansion by means of 
three silk sutures so placed as to make a longitudinal tuck in it ; others 
have excised a piece and closed the opening with sutures. 

Schanz 5 placed five stout silk sutures between the mesial border of 
the patella and the internal condyle, on tying which the capsule folded 
into a sausage-like roll. 

Delia Vedova 6 recommends a plastic operation upon the lateral ex- 
pansions by which the outer one is widened, the inner one narrowed, 
and a strip from the side of the ligamentum patellae is detached and its 
lower end fastened to the side of the internal condyle of the femur. 

Hildebrand 7 treated a case by an osteotomy of the femur, giving 
the knee the varus position. 

1 Potel : Presse Med., 1899, p. 149. 

2 Albert : Chirurgie, vol. iv. p. 396. 

3 Roux: Rev. de Chir., August, 1888. 

4 Bradford : Boston Medical and Surgical Journal, February 20, 1S96. 

5 Schanz : Zeitschrht f iir Orthop. Chir., vol. vii. 

6 Delia Vedova : Ztlblatt f iir Chir., 1909. p. 449. 

i Hildebrand : Arch, fiir klin. Chir., vol. lxvi. p. 360. 



CHAPTER LVI. 

DISLOCATIONS OF THE FIBULA. 

Of the Upper End — Of the Lower End — Spontaneous or Pathological. 

The fibula may be dislocated at its upper or at its lower end, and 
as the result of external violence, or of muscular action, or of unequal 
growth of the tibia and fibula. 

DISLOCATIONS OF THE UPPER END. 

Of these there are now about twenty-five reported cases. 1 In the 
majority the displacement was outward and forward, in others back- 
ward, and in a few upward. It is to be remembered that, as the head 
of the fibula is situated behind the most external part of the tibia, a 
dislocation forward must also be outward. 

Of cases complicated by fracture of either the tibia or fibula, or of 
both bones, quite a number have been reported. Of those in which 
the dislocation is produced by the overriding of the fragments by 
which the head of the fibula is forced upward, it is only necessary to 
say that, although the reported displacement has been very great in 
some cases, it does not appear seriously to have affected the treatment 
of the fracture, and in most cases reduction was easy. In some, in 
which the fracture united with shortening, there remained a permanent 
displacement of the head of the fibula upward. The dislocation is 
not always upward, but is sometimes forward, and sometimes the head 
has been freely movable backward and forward. 

1. Forward. 

The cause has been a fall with the leg bent under the body or a mus- 
cular effort without a fall, and there is reason to think that the forcible 
depression and inversion of the front of the foot may be a factor in 
the production ; thus, Savournin's patient caught her heel while 
descending a staircase and the foot was sharply depressed and turned 
inward, and in my two patients, one of whom had not fallen, move- 
ment of the foot in the direction mentioned caused pain at the site of 
the dislocation after reduction. Tillaux, also, observed a case of dias- 
tasis associated with fracture of the lower end of the tibia (p. 388). 

The head of the fibula can be seen and felt in front and outside of 
its normal position, and the tendon of the biceps shows plainly in an 
unusual curve. The patient is usually unable to walk because of pain, 
but can move the knee quite freely. 

1 In addition to the bibliography given in the first edition, see Hirschberg, Arch, 
fur klin. Chir.. 1888, vol. xxxvii. p. 199 ; Leggett, Lancet, March 31, 1888 ; Stimson, 
N. 'Y. Med. Jour., May 25, 1889, and Feb. 6, 1892; Golley, Am. Jour. Surg. June, 1907. 



DISLOCATIONS OF THE FIBULA. 833 

Reduction has usually been easy by direct pressure while the knee 
was partly flexed ; in Savournin's case while the knee was extended 
and the foot in dorsal flexion. I was obliged to resort to arthrotomy 
in one case. Leggett refers to an unreported case in which reduction 
failed, two attempts having been made under anaesthesia. The obstacle 
in my case appeared to be a strong fibrous band extending from the 
head of the fibula to the front of the tibia ; after its division reduction 
was easy. 

2. Backward. 

In at least one of these, Dubreuil, the cause clearly seems to have 
been forcible contraction of the biceps ; in the others the patients fell, 
and the cause may have been a twist of the leg which ruptured the 
tibio-fibular attachments by the pull of the external lateral ligament 
of the knee, the biceps then acting to displace the bone backward. 

In two cases the foot was slightly everted, and in one of them there 
was a sensation of cold and numbness along the peroneal region of the 
leg ; in one the tendon of the biceps was tense. The displacement is 
described as backward in all, and its extent as one inch in Dubreuil's. 

Kecluction was effected without much difficulty in three by direct 
pressure upon the head of the fibula while the knee was flexed. In 
DubreuiFs the displacement recurred on the following day, and was 
then less easily reduced ; a knee-cap of leather was then worn for 
twelve days, and the patient was then able to walk with a cane, but 
for some time the leg had a tendency to bend outward ; ultimately 
recovery was complete, as it was also in the other two cases. 

Erichsen and Oldright did not see their patients until some time 
after the accident ; in the former's the displacement was permanent 
and the "limb was somewhat weakened, so that the patient could not 
jump, but otherwise he suffered no inconvenience." In Oldright' s 
the displacement could be easily reduced, but it immediately recurred; 
local pressure and immobilization of the knee failed to cure. Possibly 
retention by a strip of adhesive plaster placed round the upper part of 
the leg would be effective. 

3. Upward. 1 

Of this form there are only three reported cases, Boyer, St oil, and 
Sorbets, and the account of the latter is too incomplete to be of any 
use or even to establish the accuracy of the diagnosis. 

Boyer's patient appears to have received a dislocation outward of 
the foot or a Pott's fracture of the ankle in which the fibula, instead 
of breaking, had been pushed bodily upward ; the extent of the dis- 
placement is not stated ; the restoration of the foot to its place cor- 
rected the upper dislocation also, and the patient recovered. 

In Stoll's case the head of the fibula is described as standing 
"notably higher than normal on the outer surface of the tibia, and 
forming there an immovable, firm, sharply projecting tumor, very 
painful on pressure." He quotes DubreuiFs case as identical, and 
attributes the displacement to the forcible contraction of the biceps, 
and, therefore, it seems possible that the dislocation may belong among 

1 This is sometimes called "total" dislocation, because the lower end also is displaced 
53 



834 DISLOCATIONS. 

the backward ones. The patient was a circns-rider and received the 
injury in jumping from his horse, alighting upon his toes. The sole 
was everted, the toes abducted ; the inner side of the ankle swollen 
and tender ; passive motion of the knee and ankle very painful ; numb- 
ness of the outer side of the leg. No fracture could be found. Re- 
duction was made by forcible traction on the foot, the knee being 
flexed at a right angle, and was accompanied by a snapping sound. 

DISLOCATIONS OF THE LOWER END. 

Of this the only two recorded cases, excluding, of course, the innu- 
merable ones in which diastasis of this joint has formed one of the lesions 
of Pott's fracture at the ankle and the few cases in which the same 
diastasis has been part of inward or outward dislocation of the foot, 
are one observed by Nelaton in the service of Gerdy and one in the 
service of Tillaux reported by Dunand. 1 Gerdy's patient came to the 
hospital thirty-nine days after the accident. The wheel of a wagon 
had passed across the lower end of his leg and had forced the external 
malleolus so far backward that it was almost in contact with the outer 
border of the tendo Achillis ; the outer surface of the astragalus could 
be felt through almost' its entire extent, The patient walked fairly 
well, and Gerdy thought no attempt to reduce should be made. 

In Tillaux's case the patient in stepping from an omnibus caught 
his foot and fell forward. The foot was everted, there was a large 
ecchymosis on the inner side of the leg and foot, and another on the 
outer side ; the ankle was swollen and tender, especially on the inner 
side ; no fracture could be found. The lower end of the fibula was 
freely movable forward and backward with cartilaginous crepitus, 
and could be drawn outward so far that the end of the finger could be 
inserted between it and the astragalus. The patient made a good 
recovery. 

See Torini, in Clinica Moderna, 1907, vol. xiii., p. 1037, for what 
may be another case. 

I have seen one case of dislocation backward from the tibia, possibly 
with preservation of the relations with the calcaneum. The patient, 
a lad of seventeen, was admitted to the House of Relief, July 17, 
1889, having been injured in the left ankle while wrestling. The 
foot was abducted, its inner side normal and painless ; the lower part 
of the fibula was prominent, the region swollen and tender. A care- 
ful examination was made under ether, and the above diagnosis reached. 
On adduction of the front of the foot the bone returned to its place 
with an audible snap. The dislocation was then reproduced by abduc- 
tion of the foot, and again reduced by adduction. 

SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS. 

These have been reported as occurring at the upper end in conse- 
quence of inflammation of the joint, of rhachitic changes in the bones, 
and of exaggerated growth of the tibia following necrosis. In the 

1 Dunand : These de Paris, 1878, No. 217. 



DISLOCATIONS OF THE FIBULA. 835 

same group may be classed a dislocation outward reported by Bryant, 
which was due to arrest of growth of the tibia. 

Malgaigne, after quoting a general description given by Cooper, 
according to which chronic hydrarthrosis leads to the easy displace- 
ment of the head of the fibula and to much weakness and fatigue in 
walking, describes a case under his own care in which this laxity of 
the joint existed ; in certain movements of the knee the fibula was dis- 
placed backward, returning almost at once to its place with a cracking 
sound ; the condition followed an arthritis which had produced a sim- 
ilar relaxation of the knee. In a case of rhachitic curvature of the 
leg in an infant Malgaigne thought he could recognize the head of the 
fibula displaced upward almost to the level of the articular surface of 
the tibia, and on examining the rhachitic skeletons preserved in the 
Musee Dupuytren he found several examples ; the displacement was 
upward and outward at the upper end, the lower end preserving its 
normal relations. 

Dislocation downward of the upper end due to elongation of the 
tibia following necrosis was described by Parise (quoted by Malgaigne), 
who reported three cases. In one of them the elongation was three 
centimetres on the inner side of the tibia, one and a half centimetres 
on the outer. Malgaigne subsequently saw and reported a fourth 
case. The conditions did not affect the functions of the limb. 



CHAPTER LVIL 

DISLOCATIONS AT OE NEAR THE ANKLE. 

Dislocations of the Foot (Tibio-tarsal) — Subastragaloid — Total Dislocation of 
the Astragalus — Medio-tarsal — Congenital. 

Anatomy. 

The principal movements of the foot are that of flexion and 
extension, or dorsal and plantar flexion, which takes place in the 
joint formed by the astragalus and the tibia and fibula, and that of 
adduction and abduction combined, respectively, with inversion and 
eversion of the sole, which takes place in the joints between the astrag- 
alus on one side, and the calcaneum and scaphoid on the other, and is 
aided by slight motion between the calcaneum and cuboid. The axis 
of the first joint, the ankle, is horizontal and nearly transverse, its 
inner end inclining forward ; that of the other runs obliquely from a 
point near the inner tuberosity of the calcaneum upward and forward 
to a point on the upper surface of the neck of the astragalus. 

The astragalus articulates above with the under surface of the tibia, 
and on the sides with the malleoli, between which it is so snugly placed 
that no lateral motion is possible. On each side the lateral ligament 
passes to the astragalus and calcaneum from the malleolus, and the 
lower ends of the tibia and fibula are bound together by ligaments in 
front and behind. The range of dorsal and plantar flexion is nearly 90 
degrees, and as the articular surface of the astragalus is somewhat nar- 
rower behind than in front some lateral motion of the joint is possible 
in full plantar flexion. 

The rounded head of the astragalus articulates with the posterior 
concave surface of the scaphoid, the inferior calcaneo-scaphoid liga- 
ment, and slightly with the anterior end of the calcaneum. On the 
under surface of the astragalus are two articular facets corresponding 
to two on the upper surface of the calcaneum, and between them is the 
strong interosseous ligament which fills the canal formed by a groove 
on each bone separating its two articular surfaces, and binds the bones 
firmly together. The maximum range of motion in these joints is 
about 40 degrees, and is limited partly by bony conta'ct and partly by 
the ligaments. 

In this chapter I shall describe four different dislocations : those of 
the foot, those of the astragalus, the subastragaloid, and the medio- 
tarsal dislocations ; under the first term are included those in which 
the astragalus, while maintaining its relations with the other bones of 
the foot, is displaced from the bones of the leg; under the second, 
those in which it is also displaced from the calcaneum and scaphoid ; 
under the third, those in which the astragalus remains in the tibio- 



DISLOCATIONS AT OR NEAR THE ANKLE. 837 

fibular mortise and is separated from the calcaneum and scaphoid ; and 
under the fourth, those in which the scaphoid and cuboid are together 
dislocated from the astragalus and calcaneum. 

DISLOCATIONS OF THE FOOT. TIBIO-TARSAL DISLOCATIONS. 

The displacements of the astragalus and the foot are so complex 
that the nomenclature of the various dislocations presents serious diffi- 
culties, and the confusion has been increased by the varying practices 
of different writers, some of whom treat the tibia as the dislocated bone 
and apply the terms indicative of direction to it, while others consider 
the foot as the dislocated portion. I shall here follow the latter prac- 
tice, and shall use in the classification only four main terms, disloca- 
tions forward, backward, outward, and inward, disregarding for the 
moment the many deviations in the direction of the toes and of the 
sole which are seen in conjunction with the principal dislocations. (The 
latter two are sometimes subdivided into four : pronation, supination, 
inversion, and eversion ; for the latter two names adduction and abduc- 
tion seem preferable.) Of these four the first two are pure dislocations ; 
in the latter two are frequently placed cases in which the displacement 
is associated with fracture of one or both bones of the leg, and of 
which the more common forms have been elsewhere described among 
fractures at the ankle. It must be freely conceded that the classifica- 
tion, especially in respect of the last two groups, is arbitrary and open 
to serious criticism, but so are all others that have been proposed, and 
it is believed that this one has a sound clinical basis in so far that the 
terms outward and inward correspond to displacement outward, or 
eversion, or to displacement inward, or inversion of the foot, the symp- 
toms which would at once attract the attention of the surgeon, and that 
its divisions coincide also with those of the modes of production. A 
fifth group, dislocation upward, between the separated tibia and fibula, 
may be added. 

Two striking varieties, in which the toes are turned directly inward 
or outward, will be mentioned under inward and outward dislocations 
respectively. The latter has been classified by some as a separate 
form, under the title of dislocation of the foot by rotation outward. 

The mechanism of the joint and the mode of production of the dis- 
locations have been experimentally studied by many surgeons and 
anatomists, of whom I shall here name only one, Honigschmied. 1 
whose experiments were exceptionally numerous and whose article is 
very full. Wendel 2 collected 108 cases uncomplicated by fracture re- 
ported before 1898. 

1. Dislocations Backward. 

(Syn. Dislocations of the lower end of the tibia forward ; see also 
Fractures at the Ankle.) 

In these dislocations the astragalus, and with it the foot, is displaced 
backward to a variable distance, with rupture of the lateral ligaments 

1 Honigschmied : Deutsche Zeitschrift fur Chh\, 1877, vol. viii. p. 239. 

3 Wendel : Beitriige zur klin. Chir., vol. xxi. p. 123. 



838 DISLOCATIONS. 

and sometimes of other parts of the capsule, and sometimes with frac- 
ture of one or both malleoli or of the posterior edge of the lower 
articular surface of the tibia. 

The cause is usually extreme plantar flexion of the foot, in which 
the posterior border of the end of the tibia comes into contact with the 
posterior lip of the astragalus (Henke ] ), by which a new centre of 
motion is established behind the line of the malleoli ; the continuation 
of the movement ruptures the lateral and the anterior ligaments, and 
the bones being thus freed slip past each other. The rupture of the 
ligaments is the first step, and the fixation of the astragalus behind 
the tibia takes place by correction of the plantar flexion. Commonly 
the injury is produced by a fall backward while the foot is fixed. In 
an incomplete dislocation reported by Sanson (quoted by Albert) the 
patient's leg was bent under him in a fall in such a way that the dor- 
sum of the foot and the front of the leg rested on the ground, and the 
buttocks rested on the heel ; in this case the mechanism appears to have 
been pure exaggerated plantar flexion. Examples of pure primary dis- 
location are rare ; but partial, and perhaps complete, dislocations occur- 
ring as a secondary result of rupture of the lateral ligaments or fracture 
of the fibula and internal malleolus, as in fracture by eversion at the 
ankle, are frequent, and always need to be guarded against in the treat- 
ment of this last-named injury ; they are produced either by the falling 
backward of the insufficiently supported foot, as the patient lies upon his 
back, or by contraction of the flexor muscles, and occasionally subcu- 
taneous division of the tendo Achillis has been resorted to to overcome 
or prevent it. Wendel collected 26 uncomplicated cases, of which 6 
were compound. 

Honigschmied produced the dislocation twenty times and found the 
results quite constant ; in 14 the internal lateral and the anterior branch 
of the external lateral ligament were the first to yield, being torn away 
from their insertions, then the middle and posterior branches of the 
external lateral ligament yielded, and the foot was thus completely 
freed. The ligaments were torn away, and occasionally small scales 
of bone came away with them. In 5 experiments on the bodies of 
elderly people, both malleoli were broken off in 3, and the external 
malleolus in 2. The internal malleolus broke at its base, and the line 
of fracture ran downward and backward ; that of the external mal- 
leolus ran upward and backward, beginning just above the insertion 
of the anterior branch of the lateral ligament. 

Clinically and post mortem the same lesions have been found ; frac- 
ture of the external malleolus is common, that of the internal malleolus 
and of the posterior articular border of the tibia is occasionally seen. 

The foot appears shortened in front, and the heel lengthened, to an 
extent that varies with the degree of the displacement, the maximum 
being about an inch ; the lower end of the tibia projects more or less 
markedly in front and sometimes is exposed by rupture of the skin ; 
the extensor tendons may be felt as tense cords crossing to the dorsum 
of the foot, and the tendo Achillis curves backward to the heel leaving 
on each side a well-marked depression between itself and the malleolus. 

1 Henke: Zeitschrift fur rat. Med., 1858, 3d ser., yol. ii. p. 177. 



DISLOCATIONS AT OR NEAR THE ANKLE. 839 

The toes may be a little depressed, and perhaps abducted or addueted. 
If the fibula is broken its malleolus accompanies the foot in its dis- 
placement backward. 

Reduction, with the exception of Cooper's first case, in which he 
appears not to have made the diagnosis at the time, has always been 
easily obtained by pressing the foot forward and the lower end of the 
leg backward, and the limb should then be immobilized, preferably in 
a posterior moulded splint so as more surely to prevent recurrence. 
Statzer 1 reduced one that was nine weeks old ; the internal malleolus was 
broken. 

2. Dislocations Forward. 

(Syn. Dislocations of the lower end of the tibia backward.) 

In this dislocation, which is much rarer than the preceding, the 
astragalus, and with it the foot, is displaced forward from beneath the 
tibia. Malgaigne collected only five cases, Delamotte, Colles, Nela- 
ton, Pierre, and R. W. Smith, and I can add only five more, Huguier, 2 
Sarazin, 3 Augarde, 4 Willemin, 5 and Hornby, 6 making ten in all. Wen- 
del collected 11 cases, 6 of which are new. 

The mode of production may be by dorsal flexion of the foot fol- 
lowed by impulsion of the tibia downward and backward by a force 
acting in the direction of its long axis, or by direct pressure of the 
foot forward and of the leg backward while they are at right angles to 
each other. Among the recorded cases are clear examples of each, 
such as R. W. Smith's and Nelaton's of the former, and Huguier's 
of the latter. R. W. Smith's 7 patient, while standing with the hip 
and knee flexed and with the foot resting on a stone in such a manner 
that the toes were higher than the heel, was struck upon the knee by 
a falling cask which forced it downward and increased the flexion at the 
knee and ankle. In Nelaton's case, 8 a woman, who fell from the 
fourth floor, the anterior lip of the articular surface of the tibia was 
broken off, and the upper surface of the astragalus was scratched 
antero-posteriorly. 

In the second method of production the force and counter-force act 
at right angles to the long axis of the limb, the one upon the front of 
the lower end of the tibia, the other in the opposite direction upon the 
back of the heel. Huguier's case is an example : a man, while engaged 
in turning a railway turntable, fell and caught his foot in such a man- 
ner that the heel was fixed and a projecting rail on the moving turn- 
table pressed against the front of the tibia six inches above the ankle 
and produced a well-marked dislocation of the foot forward. 

The symptoms are lengthening of the front of the foot and shorten- 
ing of the heel, with eifacement of the depressions on each side of the 

1 Statzer: Wiener klin. Wochenschrift, 1904, No. 3. 

2 Huguier: Gaz. des Hopitaux, 1855, p. 4b9, and Areh.gen.de Mod., 1868, vol. i. p. 513 

3 Sarazin : Eecueil de mem. de mod. ehir. et pharm. mil., I860, vol. iv. p. 66. 

4 Augarde : Idem, 1880, vol. xxxvi. p. 168. 

5 Willemin : L'Union med., 18G6, vol. xxix. pp. 50 and 73. 

6 Hornby: Medical Times and Gazette, 1871, vol. ii. p. 10. 

7 R. W. Smith: Dublin Quarterly Journal of Medicine, 185-2, vol. i. p. 465, 

8 Nelaton : Pathol, exierne, vol. ii. p. 477. 



840 DISLOCATIONS. 

tendo Achilles. The foot is in the position of more or less plantar 
flexion, and in one or two cases the hollow of the instep was exagger- 
ated. The upper articular surface of the astragalus can be felt in front 
of the end of the tibia, and the malleoli are nearer to the heel and to 
the sole than normal. 

In four cases reduction was easily made by traction and direct press- 
ure ; in Smith's it could not be made, but there is reason to think the 
efforts were not guided by a correct appreciation of the nature of the 
injury ; Nelaton's patient was killed by the fall ; in the remaining cases 
the details of treatment are lacking. 

3. Dislocations Inward. 

In this division are placed those cases in which, usually by adduction 
and inversion (supination), the foot is moved downward and to the 
inner side, so that the astragalus leaves the tibio-fibular mortise more 
or less completely. Two distinct forms are observed : in one the foot 
is markedly inverted and the upper surface of the astragalus can be 
seen and felt raising the skin under the external malleolus ; in the 
other the inversion of the foot is less or is absent and there is marked 
adduction, so that sometimes the ends of the toes point directly inward ; 
in the latter form it is thought that the displacement is secondary to a 
backward dislocation. If the two forms are separated the former is 
called supination, the latter adduction or inversion dislocation. Wen- 
del's list contains 36 supination (22 compound) and 3 adduction (- 
compound). 

Malgaigne includes in the group (which he terms tibio-tarsal dislo- 
cations outward) many cases complicated by fracture of the astragalus 
or of one or both bones of the leg ; but of his total of 22 cases, 8 were 
not thus complicated, and to these I can add 5, Busch, 1 Nunnely, 2 
Eames, 3 Carmichael, 4 and Spaeth. 5 I have described under " frac- 
tures by inversion and adduction of the foot" the lesions and symp- 
toms in cases in which fracture is present and the displacement is slight. 

Excluding for the moment those cases in which the displacement is 
secondary to a backward dislocation, it seems probable that the cause 
is violent supination, or inversion, of the foot, but the histories of the 
cases do not positively establish this opinion. In most the cause has 
been a fall, usually from a height. 

The astragalus fits so snugly and squarely into the tibio-fibular mor- 
tise that in a considerable proportion of cases its turn about its antero- 
posterior axis breaks the external malleolus or forces it away from the 
tibia by the pressure of the upper outer edge of the astragalus. In the 
experiments which Honigschmied made by fixing the foot in a vise and 
bending the leg directly toward the inner side — tibial flexion— the 
external malleolus was broken 5 times, the external lateral ligament 
torn from its insertion 12 times, and in 3 cases the joint remained 
unopened and separation took place between the astragalus and the 

1 Busch : Lehrbuch der Chir., vol. ii., part 3, p. 327 ; quoted by Lossen. 

2 Nunnelv : British Medical Journal, 1868, vol. ii. p. 362. 

> Eames f Idem, 1871, vol. i. p. 503. 4 Carmichael : Idem, 1871, vol. ii. p. 35. 

5 Spaeth : Miinchen. med. Wochen., January 17, 1888. 



DISLOCATIONS AT OR NEAR THE ANKLE. 841 

calcaneum. These results coincide in the main with those obtained in 
a similar manner by Bonnet, and Honigschmied accepts the latter's 
opinion that the fracture of the malleolus is effected by the direct press- 
ure upon it of the outer upper border of the astragalus and not by trac- 
tion exerted through the external lateral ligament. Bonnet frequently 
found the internal malleolus also broken, Honigschmeid never. 

In one case, Busch, in which there was no fracture, the dislocation 
was compound and the bones of the leg protruded through the wound 
in front, the astragalus lay entirely to the inner side of the internal 
malleolus, and the foot was greatly adducted ; Busch thought the dis- 
location had been primarily backward. Of Wendel's 22 compound 
cases the bones protruded in 16; 15 were reduced, 5 after resection; 
one of these died, the others made slow recoveries with useful joints. 

In some cases ? in which the displacement inward may be assumed to 
have been secondary to a backward dislocation, the adduction of the 
foot has been very great, 90 degrees, so that the toes pointed directly 
toward the other ankle ; in the others the adduction is less, but the 
inversion is great; in CarmichaePs " the plantar aspect pointed to the 
middle line of the body," in Eames's " the plantar aspect of the foot 
was completely inverted," in Spaeth's the inner border lay directly 
beneath the tibia. In some the external malleolus was very promi- 
nent ; in Xunnely's " there was a large and well marked projection 
below the outer malleolus " over which the skin was very tense, and 
" there was a deep, narrow depression at the inner malleolus where the 
skin was also very tight." 

Reduction has always been easily effected by traction and eversion 
of the foot, and in the uncomplicated cases the recovery has been 
complete. 

4. Dislocations Outward. 

Most of the displacements reported under this title have been inci- 
dental to fracture by eversion and abduction of the foot (Chapter XXV.). 
But Wendel collected 27 uncomplicated by fracture, grouping them as 
19 pronation and 8 eversion dislocations. Of the 19, 14 were com- 
pound. The sole is everted, sometimes looking almost directly upward ; 
the astragalus lies under the internal malleolus, or obliquely across the 
mortise, or, in compound cases, may be external to the external mal- 
leolus. The malleoli are separated. The 5 simple cases were reduced 
and made good recoveries. Of the 14 compound the tibia projected 
through the wound in 6 ; all were reduced, 4 after resection ; 1 death. 

In four cases, Huguier, 1 Thomas, 2 Soubie, 3 and Knust, 4 the foot has 
been so far abducted that the toes pointed directly outward. AVendel 
collected 8. This form was first observed by Huguier and described 
by him as " dislocation of the foot by rotation outward" His patient 
was overthrown by a cask, which rolled upon his legs ; Thomas's by a 
falling mass of straw ; Soubie's fell from a height of six feet, alighting 
upon his left foot, which was then engaged between a large stone and 

1 Huguier : L'Union Mediccile, 1848, p. 128. 

2 Thomas: Revue de Chirurgie, 1887, p. 821. 

3 Soubie : Quoted by Thomas. 

4 Knust: Centralblatt fur Chirurgie. 1898, p. 320. 



842 DISLOCATIONS. 

the trunk of a vine while the body was twisted to the right, and the 
patient fell on his right side ; and Knust's twisted his right foot in like 
manner, the body turning to the left. In Huguier's case the external 
malleolus was separated from the tibia, pressed backward, and rotated 
outward, and the shaft of the fibula was broken in the upper third. 
In the other two cases no fracture w r as found. Reduction was easily 
effected under anesthesia in the first three cases ; not mentioned in 
the fourth. 

In January, 1904, I saw at the Hudson Street Hospital a man forty 
years old who had injured his right ankle by slipping on the sidewalk 
an hour previously. The foot was abducted nearly 90 degrees, and 
over the internal malleolus the skin was tightly stretched, and almost 
the entire articular surface of the tibia could be easily palpated. The 
fibula was separated from the tibia below and pushed backward by the 
foot ; it was broken at the middle, without displacement. Reduction 
was easy by traction and adduction of the foot. Schubert l reports two 
similar cases with fracture of the fibula at the upper end. 

5. Dislocation Upward. 

In this the astragalus is displaced upward between the malleoli. 
Wendel collected four cases, but he gives few details and I have been 
able to consult the original report of only two. 2 The usual cause was 
a fall upon the foot ; none was compound ; reduction was easily made, 
and the result in the three cases in which it was known was good. 

6. Compound and Complicated Dislocations of the Foot. 

Dislocations of the foot may be compound, primarily or secondarily, 
with protusion of the bones of the leg or of the astragalus through 
the wound, and they may be complicated by rupture of bloodvessels 
and by other fractures than those of the malleoli already referred to. 

In dislocations that are primarily compound the wound of the skin 
ma) r be made from Avithin outward by the projecting bone or by contact 
with the ground. In those that become secondarily compound the 
sloughing of the soft parts may be due to the pressure of the unre- 
duced bones or to bruising of the soft parts inflicted at the time of 
dislocation. 

Statistics that have been collected from the period anterior to the 
introduction of antiseptic methods cannot be trusted to show the neces- 
sity or desirability of amputation or excision. Later ones (Scudder 3 ) 
show that conservative treatment may be safely tried in many cases. 
Amputation or excision is indicated when infection is certain, the 
patient feeble, or the functional result otherwise likely to be bad. 
Neither the loss of the astragalus nor anchylosis of the ankle-joint 
usually causes much disability. Particular attention must be given 
to drainage, and as the astragalus completely fills the space between 

1 Schubert : Deutsche Zeitschrift fur Chir., 1904, vol. lxxii. p. 396. 

2 Lancet 1856, ii. p. 60. 

3 Scudder : Boston Medical and Surgical Journal, April 7, 1S92. 



PLATE LXV 




Subastragaloid Dislocation. 



DISLOCATIONS AT OR NEAR THE ANKLE. 84:3 

the malleoli separate drainage must be provided for the baek and front 
of the joint. 

The limb must be carefully immobilized with the foot at a right 
angle to the leg and without inversion or eversion, in order that if the 
joint should become stiff the disability will not be increased by a 
faulty position of the foot. 

SUBASTRAGALOID DISLOCATIONS. DISLOOATON OF THE AS- 
TRAGALO-CALCANEOID AND THE ASTRAGALO-SCAPHOID 
JOINTS. 

For the establishment of this group in the classification of disloca- 
tions of the tarsal bones we are indebted to Broca, 1 who, in a remark- 
able paper read before the Soci£te" de Chirurgie in 1852, carefully 
analyzed the scattered cases that had been reported under various titles 
and gave a detailed and systematic description of the various forms of 
the injury, to which little has since been added except in amplification 
of the statistics. His plan of subdivision recognized dislocations back- 
ward, inward, and outward of the calcaneum and scaphoid from the 
astragalus. Malgaigne added a fourth variety, dislocations forward, 
and changed the nomenclature by treating the astragalus as the dislo- 
cated bone and applying the terms indicative of the direction of the 
displacement according to its position with relation to the others. I 
shall here follow Broca's use of the terms, which is in harmony with 
that used in the other dislocations. 

The dislocation, then, presents four varieties : that in which the cal- 
caneum and scaphoid are displaced inward (and somewhat backward), 
the head of the astragalus projecting on the outer part of the dorsum 
of the foot; that in which they are displaced outward; and those in 
which they are displaced directly forward or backward and downward. 
The first two are about equal in frequency and together comprise most 
of the reported cases ; of each of the last two only one or two exam- 
ples have been reported. The most notable addition to the collected 
statistics has been made by Poinsot. 2 

1. Dislocations Inward, or Inward and Backward. 

The cause is forcible inversion and adduction of the foot, usually 
combined with violence acting in the direction of the long axis of the 
leg, as in a fall from a height. The displacement is rarely, if ever, 
directly inward, but is also somewhat backward, so that the head of 
the astragalus rests partly upon the cuboid. The only autopsy is one 
made in an old case by Quenu; 3 there was shortening of the dorsum 
of the foot and elongation of the heel, and the foot was in the position 
of varus. The head of the astragalus lay upon the interarticular lines 
between the calcaneum and cuboid and the cuboid and scaphoid, over- 

1 Broca : Mem. de la Soc. de Chirurgie, 1852, vol. iii. p. 566, and abstract in Bull, do la 
Soc. de Chirurgie, 1853, vol. iii. p. 241. 

2 Poinsot: L'i intervention ehirurgicale dans les luxations oompliqiuVs <lu cou-de-pied, 
Taris. 1877, and his translation of Hamilton's Fractures and Dislocations, p. 1196 

8 Quenu : Progres Med., 1883, p. 187. 



844 



DISLOCATIONS. 



lapping the former half an inch and thus resting on the cuboid. The 
posterior border of the astragalus lay in the groove between the anterior 
and posterior superior articular surfaces of the calcaneum, and its pos- 
terior lip had been broken off and remained in its normal relations with 
the calcaneum. There was no fracture of either malleolus. The dorsalis 
pedis artery and the extensor tendons lay to the inner side of the head 
of the astragalus ; the peroneal tendons had been displaced from their 
groove and separated half an inch from the fibula. In other cases the 
displacement has been greater and the skin has been broken on the 
outer side of the foot ; in one of Malgaigne's the head of the astragalus 

Fig. 360. 




Subastragaloid dislocation inward. 



was almost in contact with the fifth metatarsal bone ; in one of Leten- 
neur's it corresponded to the outer border of the foot and projected 
entirely through a wound in the skin, and the calcaneum had been com- 
pletely displaced from its inferior articular surface. In one of my own 
the external malleolus protruded through and was tightly grasped by 
a rent in the skin ; evidently perforation had occurred while the foot 
was in extreme inversion, and I was obliged to lengthen the opening 
downward for an inch in order to reduce. The patient made a good 
recovery, with some limitation of inversion (supination) of the foot. 
The form and degree of the displacement vary with the different com- 
binations of displacement inward, backward, and by adduction of the 



DISLOCATIONS AT OR NEAR THE ANKLE. 



845 



front of the foot, the latter sometimes leaving the posterior part of 
the calcaneum less displaced inward than its front part. With the 
dislocation there are sometimes associated injury to the calcaneo- 
cuboid joint, rupture of its ligaments, and partial dislocation of the 
bones. 

The symptoms are more or less shortening of the dorsum of the foot 
and lengthening of the heel, adduction of the toes, and elevation of 
the inner border of the foot ; prominence of the tip of the external 
malleolus and of the head of the astragalus on the outer side of the 
dorsum, with marked depressibility of the soft parts below each ; the 
internal malleolus is deeply placed under the skin, and below and 
behind it can be felt the projecting sustentaculum tali, and in front of 
it the inner surface of the scaphoid. 



2. Dislocations Outward. 

Of these Malgaigne makes two varieties, distinguished clinically by 
the existence of marked abduction of the toes 
in one, and its absence in the other. In the 
former (his luxation oblique en dedans, or obliquely 
outward, according to the nomenclature here 
used) the posterior articular surface of the 
astragalus is not separated from the calcaneum, 
but the foot has turned upon the posterior cal- 
caneo-astragaloid joint, or upon the outer part 
of the interosseous ligament as a centre, and 
the scaphoid has been carried to the outer side 
of the head of the astragalus, and also some- 
times either upward or downward. In the sec- 
ond form, that without abduction of the toes, 
the foot is displaced bodily outward from be- 
neath and in front of the astragalus. The 
cause in the former is forcible abduction of the 
foot ; in the latter it appears to be either abduc- 
tion and eversion of the foot, or great violence 
exerted directly against the inner side of the 
foot, or the outer side of the lower part of the 
leg. The dislocation may be primarily or sec- 
ondarily compound, the wound in the skin cor- 
responding to the head of the astragalus which 
may project entirely through it. The tendon 
of the tibialis anticus sometimes lies along the 
inner and upper part of the neck of the astrag- 
alus, which is thus tightly held between it and 

the calcaneo-scaphoid ligament. In a case of the oblique form quoted 
by Malgaigne, in which the patient died four days alter the acci- 
dent, the outer part of the interosseous ligament in the sinus tarsi was 
entire; the inner part was ruptured. In one of the complete outward 
form, of which the specimen was dissected, and reported by Xelaton ' 
1 N^laton: Bull, de la Soe. Anatoruique. 1835, p. 38, 




Subastragaloid dislocation 
outward. (Malgaigne.) 



8 46 DISL OCA TIONS. 

(Fig. 361), the head of the astragalus rested against the inner side of 
the scaphoid, and its posterior lip was engaged in the groove in the 
upper surface of the calcaneum ; the lower part of the internal lateral 
ligament, the interosseous ligament, and the astragalo-scaphoid liga- 
ment were ruptured, and the posterior and outer part of the external 
malleolus was broken. 

The calcaneo-cuboid joint may also be injured, and the bones partly 
displaced from each other. 

The symptoms in the oblique variety are the marked abduction of 
the' foot, more or less eversion, and marked prominence of the head of 
the astragalus on the inner side ; the head is sometimes so depressed 
that the condition may be mistaken for inward dislocation of the 
astragalus. In a case reported by Boyer the displacement was slight, 
and was at first overlooked ; when recognized, it was irreducible, but 
the patient regained good use of the limb. 

The symptoms in the variety in which the displacement is directly 
outward are the marked displacement of the foot, with but little, if 
any, eversion or abduction, the axis of the leg falling to the inner side, 
and somewhat in front of the part of the foot to which it normally 
corresponds. Above the outer surface of the calcaneum and cuboid 
is a notable depression in the place of the usual prominences formed 
by the external malleolus and the head of the astragalus. The inter- 
nal malleolus is very prominent and nearer to the level of the sole, 
and below and in front of it is the projecting head of the astragalus. 
On the dorsum of the foot the scaphoid is recognizable with a depression 
behind it. 

3. Dislocation Backward. 

In this the calcaneum and scaphoid are displaced directly backward, 
the scaphoid descending to a lower level so as to lie under the head or 
neck of the astragalus. Deviation of the foot to either side would 
create forms intermediate between this and the two preceding ones. A 
number of reported cases, which were claimed to be subluxations of 
this kind, the relations between the scaphoid and astragalus being 
changed while those between the calcaneum and astragalus remained 
unchanged, were rejected by Broca as errors of diagnosis, but are 
accepted by Malgaigne as probably correct. In some of them reduc- 
tion was easy ; in others it failed, but the persistence of the displace- 
ment did not permanently impair the functions of the limb. 

Of the complete form there are only two recorded examples : the 
first is the much quoted case of Prof. Carmichael, reported by Mac- 
donald. 1 Carmichael, in his effort to avoid a fall when his horse 
stumbled and came upon his knees, leaned back in the saddle and 
thrust his feet forward ; his weight was received upon the inner side 
of the ball of the right foot, and the dislocation was thereby produced, 
the deformity being so great that it was recognizable through his boot. 
The toes were abducted about 30 degrees, the foot slightly everted ; 
the concavity of the tendo Achillis was manifestly increased and the 
heel lengthened ; the astragalus could not be felt behind the tibia. 

1 Macdonakl : Dublin Quarterly Journal Med. Sci., 1838, vol. xiv. p. 235. 



DISLOCATIONS AT OB NEAR THE ANKLE. 847 

Below and in front of the inner malleolus was a hard prominence, over 
which the skin was tense, formed by the inner surface of the astragalus. 
The most striking deformity was a prominence on the dorsum of the 
foot; "immediately in front of the tibia it presented a flat surface 
broad enough to receive the finger, from which there was an abrupt 
descent upon the anterior part of the tarsus. Over the projection 
caused by the head of the astragalus thrown on the upper surface of 
the scaphoid and cuneiform bones, the integuments were so tense that 
it was very evident a small additional force would have driven it 
through the skin." The distance from the internal malleolus to the 
end of the great toe was one inch less than on the other foot No 
fracture could be found. Flexion and extension were very painful. 
The dislocation was reduced by traction with the pulleys and direct 
pressure on the heel and leg. 

The second case was observed by Thierry, and communicated to 
Malgaigne by Broca ; the dislocation was caused by a fall upon the 
toes; the head of the astragalus was prominent under the skin, the 
front of the foot appeared shortened, the heel lengthened ; the foot was 
extended, and not deviated to either side. Good recovery. 

An irregular case of subastragaloid dislocation backward and out- 
Avard in which the scaphoid preserved its relations with the astragalus 
and the anterior portion of the line of dislocation ran between the 
scaphoid and cuneiform bones was reported by Kaufmann. 1 The dis- 
placement had existed nine months and was then treated by excision 
of the scaphoid and head of the astragalus with a good result. 

4. Dislocation Forward. 

Of this only two cases uncomplicated by fracture have been reported, 
one by Parise, quoted by Malgaigne, the other by Broca. 2 Planteau's 
report {Gaz. Med. de Paris, 1879, No. 30), sometimes quoted as a 
third case, is of Broca's. Parise's patient was injured by being 
crushed under a heavy weight, the thigh being flexed on the trunk, 
the leg on the thigh, and the foot on the leg (dorsal flexion). Nine 
months afterward the condition was as follows : the foot was at a right 
angle with the leg, a little adducted, and very slightly everted ; it 
was displaced forward, so that it appeared lengthened in front, and 
the external malleolus almost touched the tendo Achillis. The ex- 
tensor tendons on the instep were tense, and no prominence could be 
felt beneath them, but on the outer side a bony prominence could be 
felt, which was thought to be the head of the astragalus, and imme- 
diately in front was a depression which admitted the finger. The 
hollow between the astragalus and calcaneum seemed to be filled. 
Behind, the prominence of the heel was completely lost, the leg flat- 
tened, and its surface interrupted at the level of and a little below 
the malleoli by a bony prominence which raised the tendo Achillis 
and overlapped the heel nearly half an inch ; above it was another, 
less prominent, formed by the posterior articular edge of the tibia. 

1 Kaufmann: Centralblatt fur Chir., 1888, p. 369. 

2 Broca: Report by Petit of a clinical lecture. Gaz. Eebdom., L874, p. 316. 



848 DISLOCATIONS. 

There was no trace of fracture, no separation of the malleoli. There 
was slight motion in the tibio-tarsal joint ; motion in the joints of the 
tarsus was entirely lost. The patient could hardly walk without 
crutches. 

In Broca's case the displacement was much less marked, and the 
only symptoms were an increase of one centimetre in the distance from 
the internal malleolus to the great toe, and a corresponding shortening 
of the heel, and the absence of abnormal prominence of the astragalus 
in front of the tibia. By traction and pressure under chloroform the in- 
equality in the measurements was overcome and the patient, at the time 
of the report, was in a fair way to recover. So far as can be judged 
from the report, Broca did not consider the diagnosis entirely clear, and 
the symptoms as given are identical with those of Sarazin's case of 
incomplete tibio-tarsal dislocation forward. The differential diagnosis 
between these two injuries would have to be made on the existence of 
a gap between the astragalus and scaphoid in the subastragaloid dislo- 
cation, and the absence of such a gap and possibly the abnormal promi- 
nence of the upper articular surface of the astragalus in front of the 
tibia in the incomplete tibio-tarsal dislocation forward. The recogni- 
tion of either symptom might be made difficult or impossible by 
swelling. 

Deetz, 1 under the title " subastragaloid dislocation with fracture of 
the astragalus " reported a case and collected 3 others, and Thienhaus 3 
reported a fifth. In Deetz ? s case and in one of the three he collected 
(Gunzerich) the fracture was through the neck of the bone, and the 
anterior fragment, together with the rest of the foot, was displaced for- 
ward, so that there was a dislocation of the posterior facet from the 
calcaneum. But in his remaining two (Sick 3 and Mailland 4 ) the frac- 
ture of the astragalus was horizontal, and the lower fragment w^as dis- 
placed forward from the upper but retained its relation with the rest of 
the foot, so that the injury was a fracture of the astragalus, not a sub- 
astragaloid dislocation. Thienhaus does not describe his fracture, but 
the skiagram suggests that most if not all of the lower surface went 
forward with the calcaneum ; the external malleolus also was broken. 
Sick, Mailland, and Deetz reduced, the latter by open operation ; 
Gunzerich and Thienhaus removed the astragalus ; their cases were 
old. * 

Diagnosis of Subastragaloid Dislocations. 

If the date of the injury is so recent that swelling has not yet super- 
vened, or so remote that it has disappeared, the diagnosis may usually 
be made with considerable ease and certainty, but if swelling is pres- 
ent it may be very difficult. The important functional features are 
the preservation of the normal movements in the tibio-tarsal joint, 
and the loss or the exaggeration in one or the other direction of the 

1 Deetz: Deutsche Zeitschrift fur Chir., vol. Ixxiv. p. 581. 

2 Thienhaus : Annals of Surg., Feb., 1906, p. 295. 

3 Sick: Berl. klin. Wochenschrift, 1892, p. 581. 
* Mailland : Gaz. des Hopitaux, 1900, p. 1539. 



DISLOCATIONS AT OR NEAR THE ANKLE. 849 

lateral and rotatory movements of the foot which take place in the 
subastragaloid and medio-tarsal joints. As no lateral motion takes 
place in the tibio-tarsal joint, except in the position of full plantar 
flexion, the exaggeration of the normal movement to either side must 
be due, when the ankle is sound, to injury of the two last-named joints. 
The physical signs are the preservation of the relations between the 
astragalus and the bones of the leg, as shown by the normal relations 
of the malleoli to the head of the astragalus and by the absence of 
abnormal projection of the body of the astragalus in front or behind 
the tibia, the changes in length of the front part of the foot and heel, 
and the change in the relations of the calcaneum and scaphoid with 
the astragalus and malleoli. 

Treatment of Subastragaloid Dislocations. 

The statistics collected by Broca and Poinsot give 23 simple cases 
in which reduction was attempted ; to these may be added Pick's l case. 
Of these 24 reduction was successfully made in 14 and the ultimate 
result was good ; in 2 the reduction was incomplete, and 1 of these 
died of septicaemia. The 8 failures (excluding the 2 incomplete reduc- 
tions) gave 4 secondary amputations with 3 deaths, 3 secondary re- 
movals of the astragalus with 1 death, and 1 good functional result 
notwithstanding the persistence of the deformity. 

In 7 additional cases in which reduction was not attempted, 4 of 
the patients (Du Bourg, Dubreuil, See, quoted by Poinsot, and Quenu) 
had apparently good use of the limb, although in 1 of them sloughing 
and a violent arthritis followed the accident; in 1, Brown, 2 reduction 
was made after six months; in 2 (Sinnigen, quoted by Poinsot, Raffa 3 ) 
the disability was such that the patient sought relief ; Sinnigen removed 
the astragalus and external malleolus, and at the time of the report 
death by septicaemia was expected ; Raffa chiselled away the head and 
the neck of the astragalus and was then able to straighten the foot ; 
recovery without suppuration ; good result. 

In 2 cases (Verneuil, 4 Ore, quoted by Poinsot) primary excision of 
the astragalus was done, in each with a good result. In Verneuil's 
there was fracture of the astragalus and rupture of the peroneal artery; 
in Orel's an attempt to reduce had failed and gangrene of the tense 
skin was imminent. 

Of compound dislocations 17 cases were collected by Broca and 6 
additional by Poinsot in 1884, and to these 1 reported by Jackson :> and 
mine are to be added ; of these reduction was made in 11, with 2 deaths, 
with persistent suppuration apparently maintained by necrosis in 2. and 
with secondary removal of the astragalus in 1. In 1-1 reduction was 
not made ; in 3 of these primary amputation was done, in 10 removal 
of the astragalus, with 2 deaths, and in 1 the head oi" the astragalus 

1 Lick : Lancet. 1880, vol. i. p. 170. 

' 2 Brown : Lancet, 187(5, vol. i. p. 314, 

3 Raffa: Centralblatt furChir., 1885, p. '.Ml. 

* Verneuil : Bull, de la Soo. Anatoniiquc, 1872, p. 493. 

6 Jackson : Lancet, 1881, ii. p. 590. 

54 



850 DISLOCATIONS. 

became necrosed and was spontaneously cast out, the patient recover- 
ing. The results of primary removal of the astragalus according to 
these statistics are rather better than those of reduction, but, as has 
been said before, the value of these statistics as a basis for the choice 
of a method of treatment has been greatly diminished by the improve- 
ment in the methods of treatment of open wounds that has taken place 
in the last few years, and there is good reason to hope that suppuration 
and its attendant dangers will be less frequent in future. 

Reduction, which has sometimes been made by traction with the 
hands alone, more frequently has needed the aid of pulleys, even when 
anaesthesia has been employed. The knee should be flexed to relax 
the muscles of the calf, and the traction in the lateral cases should be 
downward and usually also forward, and coaptative pressure should be 
made upon the foot and leg. The cause of the irreducibility in some 
cases is not entirely clear ; it has been attributed to the engagement of 
the posterior lip of the astragalus in the groove on the upper surface 
of the calcaneum. In one case of oblique outward dislocation I was 
obliged to make a longitudinal incision along the head of the astragalus 
and disengage from beneath it the tendon of the tibialis anticus. 



TOTAL DISLOCATION OF THE ASTRAGALUS. 

("Double Dislocation of the Astragalus") 

This dislocation is a combination of the two preceding ones, the 
tibio-tarsal and the subastragaloid, the astragalus being simultaneously 
displaced from its normal relations with the bones of the leg, the cal- 
caneum, and the scaphoid. It is much more frequent than either of 
the other two and is often compound. The astragalus may be displaced 
forward, backward, or to either side, or to any intermediate position, 
and may at the same time be rotated about any of its axes, or it may 
be rotated while remaining in the tibio-fibular mortise. The varieties 
of dislocation are, consequently, very numerous, but they may be 
grouped as dislocations forward, backward, outward and forward, and 
inward and forward, these terms indicating the direction in which the 
astragalus is displaced, and dislocations by rotation, including in the 
latter only those in which the bone remains more or less completely 
within the mortise. 

The causes are varied, the most common being falls from a height 
upon the feet and violent twisting of the foot, as when it has been 
caught between the spokes of a wheel. It is seldom possible to deter- 
mine the exact mode of production in any given case, and experiment 
upon the cadaver has not done much to elucidate the subject ; but it 
seems probable that dorsal or plantar flexion and abduction or adduc- 
tion are requisite to rupture the ligaments that bind the astragalus to 
the other bones, and that then it is forced from its place by pressure 
exerted through the bones of the leg. 



DISLOCATIONS AT OR NEAR THE ANKLE. 851 

1. Dislocation Forward. 

In this form, which is very rare, the astragalus is displaced directly 
forward. To the briefly described and somewhat doubtful cases col- 
lected by Malgaigne, Delorme l added only two, in one of which (Morel- 
Lavallee) the astragalus had been rotated 180 degrees about its vertical 
axis and both malleoli were broken ; the foot was very movable on the 
astragalus, and the astragalus on the tibia. The sides of the bone 
could be distinctly felt, and its posterior surface, which looked directly 
forward. Reduction was easily made. In the other case, Barrall, the 
dislocation was compound, the head of the astragalus projecting 
through the wound and resting on the dorsal surface of the scaphoid. 
Both it and the foot w T ere freely movable. The extensor tendons and 
that of the tibialis anticus were ruptured, the malleoli and calcaneum 
were broken. 

2. Dislocation Outward and Forward. 

In this, the most common form, the head of the astragalus rests on 
the outer cuneiform and the cuboid or even on the fifth metatarsal, its 
posterior part lying just within the mortise, and is freely movable ; the 
foot is adducted and inverted and usually displaced bodily inward, so 
that the external malleolus is prominent and the internal hidden, and 
sometimes the adduction of the front of the foot is very marked and 
combined with abduction of the heel. If the dislocation is compound 
the astragalus presents in the wound, which commonly extends back- 
ward to or beyond the external malleolus. The lower end of the 
fibula may be torn away from the tibia, and either or both malleoli 
broken. With the displacement may be combined various kinds and 
degrees of rotation of the astragalus, and sometimes the astragalus 
is broken. 

3. Dislocation Inward and Forward. 

In this, the second in order of frequency, the foot is everted and 
abducted, but sometimes is bodily displaced to the outer side without 
deviation. The astragalus projects in front of or below the internal 
malleolus, and its head appears always to be depressed, sometimes so 
far that the bone must have undergone rotation of 90 degrees about its 
transverse axis. In a case reported by Hunt 2 it was so far rotated 
about its vertical axis that the head was directed toward the middle of 
the other foot. If the injury is compound the wound lies on the inner 
side and extends backward below the malleolus. It may be accom- 
panied by fracture of the malleolus. 

1 Delorme: Diet, de Med. et Chir. pratiques, 1879, vol. xxvii. p. 640. 

2 Hunt: Philadelphia Medical Times, 1872, vol. iii. p. 50. 



8 5 2 DJSL OCA TIONS. 

4. Dislocation Inward. 

A unique case is reported by Seiler. 1 The astragalus lay directly 
beneath the internal malleolus and had been so rotated that its lower 
surface looked inward. A free incision was made and the bone 
restored to its place. The internal malleolus and sustentaculum tali 
had been broken. Recovery with good function. 

5. Dislocation Backward. 

In this form, which also is rare, the astragalus may be displaced 
backward or backward and to either side, and in some of the reported 
cases the bone has been broken at the neck and only the posterior frag- 
ment has been displaced. Malgaigne 2 collected 8 cases, including one 
reported by Denonvilliers, which he places 3 among " dislocations by 
rotation in place/ 7 but which, I think, belongs here ; the cases are 
Phillips 2, Lizars, Liston, Turner, Nelaton, Denonvilliers, and one 
anonymously reported in the Lancet, 1838-39, vol. ii. p. 559. To 
these Delorme adds 5 — Blatin, Lejeune, MacCormac, Pichorel, and 
Cheever ; he also quotes Foucher as having reported two cases, but, I 
think, erroneously, one of them being Denonvilliers's case, the other 
Thierry's, a dislocation by rotation. Another case was reported by 
Munro, 4 and one by myself. 5 I saw a second in May, 1 907, and another, 
Legros Clark, is reported in MacCormac's paper, making 17 in all. In 
the eight printed in italics the bone was broken at the neck, and only 
the posterior fragment was dislocated. 6 

Of the 9 not complicated by fracture of the astragalus, the disloca- 
tion was backward in 6, backward and outward in 1, Turner, and back- 
ward and inward in 2, Lancet, Munro. Reduction was made in 3 
{Lancet, Blatin, Munro), and failed in 4, the functional result being 
good in 3 of the latter ; Turner, and apparently Nelaton, removed the 
astragalus. 

Of the 8 complicated by fracture, the displacement in Lejeune's is 
described as backward, in the others as backward and inward ; the 
difference is slight, for in the latter the most prominent part of the 
astragalus projects but little beyond the level of the side of the internal 
malleolus. The tendons of the flexor longus digitorum and tibialis 
posticus are displaced upon the inner side of the malleolus, and that 
of the flexor longus pollicis sometimes lies to the outer side of the 
astragalus and sometimes is pushed directly backward by it. The 
fragment is also rotated, so that its trochlear surface looks inward, 
and its fractured surface is directed forward and downward. The line 
of fracture runs from the anterior border of the trochlea into the groove 

1 Seiler : Correspblt. far Schweiz. Aertze, August 15, 1893. 

2 Malgaigne : Loc. cit., p. 1058. 3 Malgaigne : Loc. cit., p. 1060. 

4 Munro: Lancet, 1859, vol. ii. p. 364. 

5 Stimson : New York Medical Journal, May 28, 1887, p. 594. 

6 The following are two of the references : MacCormac (and Clark's case), Transactions 
of the Pathological Society of London, 1875, vol. xxvi. p. 174, with plate of specimen ob- 
tained two years later; Cheever, Boston Medical and Surgical Journal, 1875, vol. xciii. 
p. 237. 



DISLOCATIONS AT OR NEAR THE ANKLE. 853 

occupied by the interosseous ligament. In 3, Lejeune, MacCormae, 
Denonvilliers, the injury was compound ; in Cheever's the skin over 
the astragalus sloughed, but the ulcer soon healed without having 
exposed the bone. 

Reduction was made in none, although Pichorel divided the tendo 
Achillis, and Cheever successively divided the tendo Achillis, the tibi- 
alis anticus and posticus, the flexor longus digitorum, and the flexor 
longus pollicis at the toe. In three, MacCormac, Clark, Cheever, the 
patients recovered with good use of the limb ; in 1, Pichorel, suppura- 
tion followed and the limb was amputated ; in 2, Denonvilliers, Stim- 
son, the posterior fragment was removed and both patients died, mine 
of pneumonia on the ninth day. The result in Lejeune' s is not stated. 

The astragalus can be felt behind the ankle, either pressing the tendo 
Achillis backward or lying on one side of it. If the entire bone is 
displaced the absence of the head from its normal position is shown 
by the depressibility of the soft parts behind the scaphoid. Marked, 
incorrigible flexion of the terminal phalanx of the great toe is noted 
in three of the cases. In mine the tendons of the peroneus longus and 
brevis were displaced upon the outer side of the external malleolus. 

In the three cases in which reduction was made the means employed 
were traction followed by extension of the foot, traction, direct pressure, 
and inversion of the foot, and traction and direct pressure ; in Munro's 
case several months elapsed before the patient regained good use of 
the limb. 

6. Dislocation by Rotation. 

In this class are not included those numerous cases in which the bone 
has undergone rotation in connection with displacement from the tibia 
and fibula, but only those in which it still lies mainly within the 
mortise. 

Two distinct varieties of this class may be made ; those in which the 
bone has been rotated upon its vertical or transverse axis, and also, 
perhaps, upon the antero-posterior axis, but still remains in great part 
within the mortise ; and those in which the bone still lies almost exactly 
in its normal position between the malleoli and has undergone only 
rotation about its antero-posterior axis. 

The division between the first variety and that of dislocations for- 
ward and inward is rather arbitrary and is perhaps not always to be 
made clinically, and the three cases collected by Malgaigne differ 
notably from one another. Barwell, 1 in a valuable paper containing 
a well-observed and well-reported case of his own and abstracts of all 
the other alleged cases except Chevallez's, proposes to term the injury 
dislocation of the foot with version, or with torsion, of the astragalus, 
applying the term version to the cases of rotation about the vertical 
axis, and torsion to those of rotation about the antero-posterior axis. 
I see no sufficient reason for using the term dislocation of the toot. 
which has already been employed for another form of injury ; and 
version and torsion do not in themselves indicate the sense in which 
they are used, but must be accompanied by a definition. 

1 Barwell : Medico-Chirurgical Transactions, 1883, vol. Ixvi. p. .">!>. 



854 DISLOCATIONS. 

Malgaigne gives four cases of rotation about the vertical axis, but 
I have placed one of them, Denonvilliers, among the dislocations 
backward. To the remaining three Barwell adds two reported by 
Verebely; 1 in three of them the head of the astragalus lay below the 
internal malleolus, in one just behind it, and in one just in front of 
the external malleolus. As they cannot well be grouped I give a sum- 
mary of each. 

Laumonier : The head of the astragalus protruded under the internal 
malleolus between the tendons of the tibialis posticus and flexor longus 
digitorum, the trochlea lying transversely in the mortise and forcing 
apart the tibia and fibula. 

Foucher: 2 The specimen was taken from a subject found in the 
dissecting-room. The astragalus had been rotated 90 degrees about its 
vertical axis, the trochlea being still upright in the mortise, and the 
head below the internal malleolus. The tendon of the tibialis posticus 
and the posterior tibial artery lay in front of the internal malleolus. 
The posterior half of the astragalus lay on the calcaneum, the latter 
bone lying under the external malleolus and displaced forward and 
outward, and its axis directed forward and inward. The cuboid was 
partly dislocated downward from the calcaneum. There was no cica- 
trix ; the foot was flattened, the heel shortened. 

Thierry : The head of the astragalus projected midway between the 
internal malleolus and the tendo Achillis, the outer border of the foot 
was much raised, and it was then seen that the bone was also so turned 
that its upper surface looked forward and inward, the tibia resting on 
the internal lateral face of the body of the bone, and the internal border 
of the trochlea exactly occupied the angle between the internal mal- 
leolus and the under surface of the tibia. Amputation ; recovery. 

Verebely : Male, twenty-nine. Fibula fractured above the malle- 
olus. Under the internal malleolus the skin was very tense ; about 
an inch lower there was a hard bony prominence about half an inch 
in diameter. Reduction failed. At the end of the third week an 
abscess was opened, and it was seen that the prominence under the 
malleolus was the head of the astragalus. After four months 7 treat- 
ment the man could with difficulty put the foot to the ground. 

Verebely, second case : Male, forty-five. The foot was at right 
angles with the leg, the sole looking somewhat inward and upward. 
" Under the easily distinguishable outer malleolus and in front of it a 
long projection half an inch in diameter may be plainly felt ; this can 
be moved without much pain backward and forward independently of 
the other bones. Behind the scaphoid is a considerable hollow." 
Reduction failed. 

Of the second variety, rotation about the antero-posterior axis, Mal- 
gaigne gives seven cases, most of which Barwell rejects because of the 
incompleteness of the description or because the astragalus was more 
or less displaced from the mortise. Rejecting Boyer's, Smith's, Lis- 
ton's, and two of Dupuytren's, there still remain Malgaigne's own and 

1 Verebely : Wiener med. Wochenschrift, 1869. vol. xix. pp. 279 and 296. 

2 Foucher : Bull, de la Societe Anatomique, 1854. vol. xxix. p. 388. 



DISLOCATIONS AT OR NEAR THE ANKLE. 855 

one of Dupuytren's ; to these are to be added BarwelPs and Cheval- 
lez's. 1 In all four cases the condition was shown by direct examina- 
tion : Malgaigne describes a specimen from an old case, Chevallez's 
patient was killed by the fall that caused the dislocation, and Dupuy- 
tren and Bar well excised the astragalus. In Malgaigne's, Chevallez's, 
and BarwelPs the rotation was outward, that is, the upper surface of 
the trochlea had become external and rested against the inner face of 
the external malleolus, although in Malgaigne's the rotation was some- 
what less than 90 degrees ; in Dupuytren's the bone was turned com- 
pletely upside down, rotation of 180 degrees. 

Of Malgaigne's specimen, which is represented in his Atlas, Plate 
XXX., Fig. 5, it is said that the head of the astragalus rested on the 
scaphoid and cuboid ; its trochlea, turned outward, corresponded almost 
entirely to the inner facet of the fibula, and its inner side lay under 
the tibia. The rotation, however, was not a complete quarter of a 
circle, for a portion of the outer side of the body of the astragalus 
could still be seen partly in contact with the point of the external 
malleolus and looking downward and outward. There was bony 
anchylosis between the astragalus and calcaneum, and it was evident 
that the man had walked only on the outer border of his foot. 

In Chevallez's specimen there was subluxation of the head of the 
astragalus on the scaphoid, the upper surface of the trochlea was 
turned outward, the calcaneum was broken transversely and its pos- 
terior fragment driven up behind the astragalus ; the lateral ligaments 
of the ankle were detached, and the anterior border of the lower end 
of the tibia was broken. 

Dupuytren's patient was a man fifty years old, who had jumped 
from a ladder, alighting on his heel. There was a large, hard, irreg- 
ular, and irreducible prominence in front of the tibia and extending 
to the instep. An incision was made parallel to the axis of the foot, 
and the head and neck of the astragalus were immediately brought 
into view. Efforts to remove the bone failed, for the posterior part 
was grasped and held fast between the tibia and calcaneum. On seek- 
ing for the cause of this fixation it was found that the astragalus was 
turned around in such a way that its upper surface was directed down- 
ward, its lower upward, and that the hook-like process at its inferior 
and posterior part was fixed beneath the tibia so as completely to 
frustrate our efforts to extract it. The patient did well. 

BarwelPs patient, a man twenty-eight years old, was injured by the 
overturning of his wagon. When seen an hour and a half after the 
accident the foot was greatly inverted, its front somewhat turned in, 
the heel raised. The inner malleolus was much hidden ; beneath it the 
skin was thrown into two ridges by three deep folds drawn in segments 
of concentric circles from a centre a little above the malleolus. The 
outer malleolus projected abnormally, the skin over it was rather 
tightly drawn. About an inch in front of it and a little below it< 
level was a rounded projection, which also somewhat stretched the skin. 
An inch and a half up' the leg and in front of the fibula was a small 
1 Chevallez: Bull, de la Soc. Anatomique, 1870, vol. xlv.p. 406 



856 DISLOCATIONS. 

but deep wound. Below and in front of the inner malleolus deep 
pressure revealed absence of the usual bony substratum, the finger 
sank into a hollow bounded in front by the tuberosity of the scaphoid, 
which lay abnormally near the malleolus. The rounded projection in 
front of the external malleolus could readily be recognized as the head 
of the astragalus. A little way behind this was a ridge of bone, also 
evidently a part of the astragalus ; it led from the head backward and 
a little upward, disappearing under the upper part of the malleolus, at 
the angle between it and the anterior edge of the tibia. This ridge was 
markedly convex outward. The extensor tendons, pressed together, 
ran in a bundle a little distance inside the rounded projection. The 
wound communicated with the injury. No fracture could be detected. 

It was seen that the relations of the astragalus to the other bones 
were altered, although it was still within the mortise, but the exact 
nature of the injury was not recognized. Various attempts were made 
to reduce, and even the tendo A chillis was divided, but in vain ; a 
moulded splint was applied, and the wound dressed with carbolic acid. 

Two days later a semilunar incision was made from the middle of 
the lower end of the tibia across the head of the astragalus to the tip 
of the outer malleolus, the flap turned up, and the bone fully exposed. 
It was a little turned on its vertical axis, the head having moved out- 
ward, and 90 degrees on its antero-posterior axis, the trochlea being in 
contact with the cartilaginous surface of the external malleolus. The 
inner upper angle of the trochlea fitted closely into the reentrant angle 
formed by the external malleolus and the tibia. The bone was not at 
all displaced forward — that is, it did not protrude abnormally from its 
socket. The interosseous ligament had been ruptured ; the few remain- 
ing fibres were divided, and the bone removed. Examination of the 
cavity failed to show any fracture or detachment of cartilage. The 
patient made a good recovery, and was discharged nine and a half 
weeks after the operation. 

Treatment of Total Dislocations of the Astragalus. 

The statistics, collected by Broca, Dubreuil, and Poinsot, show that 
of 121 cases of dislocations not compound, 43 were successfully 
reduced, and it is worthy of note that Poinsot's list, composed of 
cases reported between 1864 and 1883, shows 19 reductions in 31 
cases, about 60 per cent., and as many of Broca 7 s cases were treated 
without the aid of anaesthesia it may reasonably be hoped that Pom- 
sot's percentage is an indication of the success that will be obtained in 
the future. Primary extirpation of the astragalus was done in 9 of the 
121 cases, with 6 successes, 1 death, and 2 deaths after secondary am- 
putation. Consecutive extirpation was done in 41 cases, with 39 suc- 
cesses and 2 deaths. Of 15 cases in which the dislocation remained 
unreduced and in which the result is known (excluding those of sec- 
ondary extirpation) the functional result in 8 was good. 

Of 63 compound dislocations, collected by Broca, reduction was 
made in 9, and of these 9 cases 6 recovered, secondarv removal of the 



DISLOCATIONS AT ON NEAR THE ANKLE. 857 

astragalus was done in 2, and 1 died. Poinsot adds 2 eases in which 
reduction was made ; 1 was successful, in the other extirpation became 
necessary. 

In 58 compound cases primary removal of the astragalus was done, 
with 42 successes, 14 deaths, and 2 consecutive amputations followed 
by death. 

For reasons that have been already given, we have the right to 
expect better results in the future in compound cases, and may feel 
encouraged to make reduction whenever it is possible. Expectation 
in irreducible compound dislocations has almost always ended in 
removal of the astragalus, or amputation, or death, and the cases will 
probably be very few in which primary removal of the astragalus will 
not give the patient the most speedy recovery, the least risk, and the 
most useful limb. 

Of 56 simple irreducible dislocations contained in these statistics, 
suppuration of the joint and sloughing of the skin followed in at least 
41, and there is not much reason to suppose that the frequency of this 
result will be much, if at all, diminished in the future, for the excit- 
ing cause — bruising, pressure, and destruction of the blood-supply of 
the astragalus — will be repeated. It is important, therefore, to deter- 
mine the proper course to be pursued under such circumstances. In 
1884 Dr. McBurney, of New York, successfully reduced a dislocation 
forward and inward by exposing the head of the astragalus through 
an incision, and lifting the tendon of the tibialis anticus which tightly 
embraced the neck of the bone and had prevented reduction ; other 
equally good results have since been obtained by the same means. 
Primary removal of the astragalus is recommended by Barwell in all 
cases in which "certain and sufficient but not too persevering, attempts 
at reduction " have failed, and the facts that four-fifths of the cases 
left to themselves have ended in suppuration and secondary removal 
of the astragalus, and that the functional result after removal is good, 
will be generally accepted as a justification of the advice, but it needs, 
I think, to be conditioned upon the failure of reduction by arthrotomy. 

In short, the plan to be pursued in simple cases is to attempt reduc- 
tion by traction upon the foot with the hands or pulleys, under anaes- 
thesia, and with the knee flexed, and by direct pressure so applied as 
first to correct such rotation of the bone as may exist, and then to 
force it back into place. This failing, expose the bone by incision, and 
seek to remove the obstacle to reduction and then to reduce ; this also 
failing, remove the astragalus. In cases in which the astragalus is not 
only dislocated but also broken, I think primary removal is the safest 
plan, even in cases of backward dislocation of the posterior fragment, 
although in three such treated without removal the patients recovered 
with useful limbs. 

In compound dislocations reduction is to be sought unless the 
astragalus is entirely detached or the lacerations are so extensive that 
suppuration is unavoidable ; otherwise, primary removal of the astrag- 
alus, or amputation if clearly indicated. 



858 DISLOCATIONS. 



MEDIO-TARSAL DISLOCATION. 

In this the dislocation takes place in the medio-tarsal joint, the 
scaphoid and cuboid being together displaced from the astragalus and 
calcaneum which preserve their relations to each other and to the 
bones of the leg. Broca, in the paper above quoted, pointed out that 
most dislocations previously reported under this title were actually 
subastragaloid. Partial dislocation of the cuboid from the calcaneum 
appears to be frequently associated with subastragaloid dislocations, 
but the cases in which the medio-tarsal joint alone is involved are few. 
Cases too briefly described to be positively accepted were reported by 
J. L. Petit, Liston, and Cooper, but more recently four cases have 
been placed on record in two of which the diagnosis was confirmed at 
the autopsy. Thomas l reported a case in the service of Denonvilliers ; 
the patient's foot had been crushed by the wheel of a cart. The plan- 
tar surface was convex, the dorsum so swollen that the bones could 
not be felt ; the foot was shortened, and its anterior portion could be 
moved laterally, but the movements were painful and accompanied by 
crepitus. The diagnosis of fracture of the head or neck of the astrag- 
alus and rupture of the calcaneo-cuboid ligaments was made. The 
patient died of erysipelas, and at the autopsy the tibio-tarsal and cal- 
caneo-astragaloid joints were found intact ; the head of the astragalus 
and the cuboid surface of the calcaneum formed a very marked abnor- 
mal prominence above the second row of the tarsus ; the scaphoid was 
fractured antero-posteriorly, and its outer fragment projected on the 
plantar surface ; the cuboid was still in contact with the inferior half 
of the anterior end of the calcaneum ; the superior medio-tarsal liga- 
ments were ruptured, and the inferior calcaneo-scaphoid partly 
detached ; the inferior calcaneo-cuboid was unbroken. 

Anger's 2 patient was injured by a fall from a height. There was 
slight flattening of the arch of the foot, without deviation, and with 
considerable ecchymotic and inflammatory swelling. He died of ery- 
sipelas. At the autopsy the head of the astragalus was found above 
and in front of the scaphoid, and the cuboid facet of the calcaneum 
upon the upper surface of the cuboid. The superior calcaneo-scaphoid 
and internal calcaneo-cuboid ligaments were ruptured and torn from 
their anterior insertions. It was difficult to reduce the dislocation even 
after dissection. The only fracture was of the anterior part of the 
scaphoid, the tubercle of which was almost entirely torn away. 

In the third case, Ward, 3 the dislocation was old. " The foot pre- 
sented a remarkably twisted appearance, the anterior part being directed 
considerably inward, and the inner edge somewhat elevated. The 
dorsum was shortened one inch. The anterior ends of the calcaneum 
and astragalus projected distinctly on the dorsum. The external mal- 
leolus had been fractured. 

In the fourth, Fuhr, 4 the dislocation was outward. The patient was 

1 Thomas : Mem. de la Soc. Med. d'lndre et Loire, 1887, quoted by Duplay and Delorme 

2 B. Anger : Traite iconographique, p. 334. 

3 Ward : Transactions of the Pathological Society of London, 1849-50, p. 254. 
* Fuhr: Munch, nied. Woch., March 8, 1892. 



DISLOCATIONS AT OR NEAR THE ANKLE. 859 

sixty-six years old and bad fallen six feet; the foot was slightly pro- 
nated and the projection of the posterior surfaces of the scaphoid and 
cuboid could be distinctly felt in front of the external malleolus. 

CONGENITAL DISLOCATIONS OF THE ANKLE-JOINT. 

Kraske 3 exhibited at the Ninth Congress of the German Surgical 
Society two patients, father and son, with congenital dislocation of 
both ankles, and also the two legs of another child of the same father 
which had died in infancy and had been similarily affected. The 
abnormality was a subluxation outward accompanied by, and probably 
due to, defective development of the fibula. In all three cases the 
middle and upper part of the fibula was lacking, but in the specimen 
a small upper epiphysis existed. In the father the lower end of the 
fibula was only four centimetres long and was obliquely placed, the 
apex directed outward. The articular surface of the tibia was also 
oblique, looking downward and outward ; the foot was flattened, mark- 
edly abducted, and moderately pronated. The legs, compared with 
the thighs, were abnormally short and slight. 

Eesection of both ankles had been done upon the son to correct the 
faulty position of the foot : on the right side the internal malleolus 
and a comparatively large part of the astragalus had been removed ; 
on the left, the entire lower end of the tibia and a small piece of the 
astragalus. 

Other forms of congenital subluxation belong to the subject of 
clubfoot. 

1 Kraske : Beilage zum Centralblatt fur Chir., 1882, No. 29, p. 85. 



CHAPTEE LVIII. 

DISLOCATIONS OF THE TAKSAL AND METATAESAL BONES 
AND OF THE TOES. 

In addition to the dislocations described in the preceding chapter, 
the bones of the tarsus may be dislocated separately and in various 
combinations. None of the different kinds has occurred with suffi- 
cient frequency to permit systematic grouping and description, and in 
most of them the exact nature of the injury cannot be said to have 
been positively established, for the difficulties of the diagnosis upon 
the living are usually very great and the surgeon is limited to the 
recognition of the more prominent features. I shall confine the 
account of them mainly to the enumeration of the different varieties 
that have been observed, with bibliographical references for the con- 
venience of those who may desire to examine the reports in detail. 

Calcaneum. Malgaigne quotes a case in which the calcaneum was 
bodily displaced to the outer side, but apparently was not entirely sep- 
arated from the astragalus and scaphoid. Reduction was easy. Also 
a second, Canton, 1 found upon the cadaver, in which the calcaneum 
was displaced to the outer side together with the external malleolus ; 
its anterior end lay between the cuboid and scaphoid, almost in con- 
tact with the third cuneiform ; and the astragalus was rotated inward 
about 45 degrees. 

Scaphoid. 2 The scaphoid has been totally displaced forward upon 
the dorsum in 5 cases, forward and inward in 1, inward in 2, toward 
the sole in 1, and outward on the dorsum in 1. Two were reduced 
without, and one by operation, 3 were left unreduced with a good 
functional result, in 1 the bone was removed, and in 2 amputation was 
done because of gangrene. 

The scaphoid has been dislocated forward and outward in connection 
with the astragalus, the dislocation being compound (Burnett), forward 
and inward (Rizzoli, quoted by Poinsot), upward and backward in con- 
junction with the first and second cuneiforms and the first two meta- 
tarsals and with dislocation of the third metatarsal and fracture of the 
cuboid (Chassaignac 3 ), upward and inward in conjunction with the first 
cuneiform (Lonsdale 4 ), or with the middle cuneiform (Clarke 5 ), or out- 
ward, upward, or inward alone (Pi£dagnel, Walker, R. W. Smith, 
quoted by Malgaigne, Bryant 6 ), or from the cuneiforms only, as seen 
by Garland 7 in a case that was compound. In a case reported by 

1 Canton : Lancet, 1847, vol. i. p. 505. 

2 See Capillery and Ferron : Rev. de Chir., vol. xxxiv. p. p. 93 and Eichel, Deutsche 
Ztschft fur Chir., vol. lxxxviii. p. 324. 

3 Chassaignac : Bull, de la Soc. de Chir., 1861, vol. i. p. 307. 

4 Lonsdale : Lancet, 1857, vol. ii. p. 192. 

5 Clarke : London Medical Times, 1851, vol. hi. p. 233. 

6 Bryant : Surgery, 3d American edition, 1881, p. 813. 

7 Garland : Lancet, 1857, vol. ii. p. 270. 



DISLOCATIONS OF THE METATARSAL BONES. 861 

Enos l the cuneiform bones and the cuboid were displaced outward 
from the scaphoid and calcaneum. 

Cuboid. The only case of dislocation of the cuboid of which I have 
knowledge, except in connection with other dislocations as above 
described, is one reported by Bell, 2 in which it was displaced upward 
in connection with the fifth metatarsal by inversion and adduction of 
the foot. Reduction was made. 

Cuneiform Bones. All three cuneiform bones and the second and 
third have been displaced together, and the first and second have been 
displaced separately. Isolated dislocations of the first are the most 
frequent, Lemoine 3 collected eleven such cases, to which may be added 
two observed by Bryant ; 4 the displacement is usually upward and 
inward, in only one case downward and inward (Fitzgibbon 5 ) ; some- 
times the bone is displaced from all the three with which it is normally 
in contact, sometimes the first metatarsal is displaced with it. The 
symptoms are flattening of the arch of the foot, prominence of the 
displaced bone, and a depression at its normal site. In some cases 
reduction has been easily made ; in others the attempt has failed. 

The second cuneiform has been separately dislocated upon the 
dorsum in seven cases, Foulker, 6 Laugier, Lagrade (quoted by Del- 
orme 7 ), and Haffner, 8 4 cases, the displacement being slight in one and 
nearly complete in the others, and accompanied in one by other serious 
injuries of the foot, and followed in another (Foulker) by sloughing of 
the skin, grave symptoms, and ultimate recovery. In a case of multiple 
injuries of the foot reported by Lagrange 9 the second cuneiform was 
displaced upward from all its connections except that with the scap- 
hoid. 

The second and third cuneiforms were displaced together upon the 
dorsum in a case reported by Key (quoted by Malgaigne) ; the dislo- 
cation, which was incomplete, was caused by direct violence and accom- 
panied by extensive laceration of the skin. The patient died. 

All three cuneiforms have been reported displaced together upon the 
dorsum in several cases, but it does not always appear in the histories 
whether or not they were separated only from the scaphoid or also 
from the cuboid and metatarsals ; in one of them, Bertherand 10 they 
were accompanied by the metatarsals and the dislocation could not be 
reduced. 

In Blecher's u they were totally separated ; the second and third lay 
on the dorsum, the first in the sole ; they were removed by operation, 
with a fair functional result. 

1 Enos : New York Journal of Medicine, 1857, vol. vii. p. 98. 

2 Bell : New York Journal of Medicine, 1859, vol. vii. p. 329. 

3 Lemoine : Revue de Chirurgie, 1883, vol. iii. p. 118. 

4 Bryant : Loc. cit. , p. 813. 

5 Fitzgibbon : Dublin Journal of the Medical Sciences, 1S77, vol. ii. p. 271. 

6 Foulker : Lancet, 1856, vol. ii. p. 283. 

7 Delorme: Diet, de Med. et Chir. prat. vol. xxvii. art. Pied. 

8 Haffner: Beitrage zur klin. Chir., vol. Iii. p. 573. 

9 Lagrange : Bull, de la Soc, Anatomique, 1871, p. 180. 

10 Bertherand: Bull, de la Soc. de Chir., 1856-57, vol. vii. p. 361. 

11 Blecher : Deutsche Ztschft fiir Chir., vol. Mil. p. 332. 



862 1) ISL C A TIOXS. 

DISLOCATIONS OF THE METATARSAL BONES FROM THE TARSUS 
AND FROM ONE ANOTHER. 

Malgaigne collected twenty-one cases of the various dislocations, 
Hitzig, 1 twenty -nine ; Bayer, 2 sixty-eight ; and Fischer, 3 eighteen of 
the first metatarsal. 

The first metatarsal is much more frequently dislocated than the 
others, and the displacement has generally been upward. In one case, 
Demarquay, 4 the base lay under that of the second metatarsal ; and the 
other end of the bone was also dislocated, compound ; Demarquay 
removed the bone. Fischer saw four such double cases. A frequent 
cause has been a fall while on a horse, the pressure of the stirrup against 
the inner and under surface of the bone apparently causing the injury. 
The symptoms frequently indicate the coexistence of a sprain of neigh- 
boring joints. Reduction has always been easy by traction and direct 
pressure. 

Isolated dislocation of the second metatarsal upon the dorsum has 
been reported in one case, Brault and Belin, quoted by Hitzig ; that of 
the third downward and backward in one, Tufnell ; 5 that of the fourth 
upon the dorsum in three, Malgaigne, Surmay, 6 and Gosselin. 7 

The fourth and fifth metatarsals have been together dislocated upward 
and inward, Monteggia, and upward and backward, South ; both quoted 
by Malgaigne. The third and fourth, Hartmann, and the first and 
second, Marit, have been together displaced ; both quoted by Delorme. 8 
The first, second, and third were dislocated together upon the dorsum 
in two cases, Laugier, quoted by Malgaigne, and Wilms, quoted by 
Hitzig, and downward into the sole in a case reported by Tufnell ; 9 in 
the latter case the injury was caused by the fall of a horse and was 
irreducible, but the patient recovered good use of the limb ; the later 
history is recorded in the same journal, 1855, vol. xx. p. 302. 

Dislocation of the second, third, and fourth together upon the dor- 
sum was seen by Malgaigne once ; the same diagnosis was made by 
him in another case, but at the autopsy it was found that the fifth was 
also partly dislocated from the cuboid and that the first together with 
the internal cuneiform was displaced inward. A case is reported by 
Favier. 10 

Dislocation of the first four metatarsals have been reported in four 
cases, Malgaigne, Hitzig, Demarquay, u Ely ; 12 in Malgaigne's the first 
three were displaced downward, the fourth upward ; in Ely's the first 
inward, the others upward and outward ; in the other two the clis- 

1 Hitzig : Berl. klin. Wochenschrift, 1865, p. 393. 

2 Bayer : Sammlung klin. Vortrage N. F., No. 372. 

3 Fischer: Deutsche Zeitschrift fur Chir., vol. lxxiv. p. 55. 
4 Demarquay : Bull, de la Soc. de Chir., 1870, vol. x. p. 35. 

5 Tufnell : Dublin Quarterly Journal of the Medical Sciences, 1855, p. 302. 

6 Surmay: Bull, de la Soc. de Chir., 1876, vol. ii. p. 579. 

7 Gosselin : Gaz. des Hopitaux, 1876, p. 755. 

8 Delorme: Diet, de Med. et Chir., prat. vol. xxvii. art. Pied. 

9 Tufnell : Dublin Quarterly Journal of the Medical Sciences, 1854, vol. xvii. p. 65. 
10 Favier: Arch, de Med. et Pharm. mil., November, 1888. 

11 Demarquay : Gaz. des Hopitaux, 1865, p. 531. 
12 Ely: Annals of Surg., Aug., 1906. 



DISLOCATIONS OF THE METATARSAL BONES. 863 

placement was upward. Malgaigne was able to reduce the fourth, 
Demarquay the first, and Hitzig all ; notwithstanding the persistence 
of part of the dislocation the two patients had good use of the limb. 

All the metatarsal bones may be displaced together upward, inward, 
downward, or outward ; of the latter two forms only one example of 
each has been reported. Smyly 1 saw all five bones dislocated down- 
ward by the fall of a wagon which pressed the heel forward while the 
toes w r ere fixed ; reduction was made. The case of dislocation inward 
is Kirk's, quoted by Malgaigne, who distrusts the diagnosis. 

Of dislocation outward ten cases have been reported : Laugier and 
Lacombe, quoted by Malgaigne, Tutschek, quoted by Hitzig, Mignot- 
Dan.ton, 2 Despres, 3 and five quoted by Bayer. The interlocking of 
the base of the second metatarsal between the first and third cuneiform 
bones must make a lateral dislocation impossible except as secondary to 
one upward or downward or unless accompanied by fracture ; in 
Laugier's and Despres' s the second metatarsal was broken at its upper- 
end, and in Mignot-Danton's and Lacombe's the third was broken. In 
four cases reduction was made. 

Dislocation upward may be complete or incomplete, and sometimes 
the whole or part of the first cuneiform remains attached to the first 
metatarsal and is displaced with it. Hitzig collected eleven cases. 
The most frequent cause is direct violence, but in two cases it was mus- 
cular action, the efforts of the patients to avoid falling after having 
slipped w T hile carrying heavy bundles. The autopsies and the com- 
pound cases have shown rupture of the dorsal and of some of the 
palmar ligaments, rupture and laceration of some of the interosseous 
ligaments and muscles, fracture of some of the metatarsal bones and 
occasionally of the cuboid and first cuneiform, and sometimes separa- 
tion of the first or fifth metatarsal laterally from the others. Tlx* 
metatarsus may remain in line with the rest of the foot or be deviated 
to either side, and the bases of its bones form a transverse ridge either 
corresponding exactly to the line of the joints or at a somewhat higher 
point upon the tarsus. Reduction was made more or less completely 
in some of the cases ; in others it failed, but the patients gradually 
recovered the use of the limb ; in one compound case, Mazot, primary 
amputation was done. 

SUBLUXATION OF THE HEAD OF A METATARSAL BONE. 

In the severest form of this affection, first described by Dr. T. G. 
Morton, 4 the head of the fourth metatarsal — less frequently the third 
— appears to be displaced from its normal relations with the adjoining 
one on each side, and also with its toes. The most recent paper on the 
subject, one whicli contains a full bibliography, is by Jones and 
Tubby; 5 the reader is referred to it for the pathology, symptoms, and 
treatment. It seems appropriate here to refer only to the severe 1 form 

1 Smyly: Dublin Quarterly Journal of the Medical Sciences, 1854, vol. xvii. p. 317. 
'-' Mignot-Danton : Arch. gen. de M6d., 1S66, vol. ii. p. 405. 
"-Despres: Bull, de la Soc. Anatomique, 187S. 
4 Morton: Amer. Journ. Med. Sci., January, 1876. 

f) Jones and Tubby: Mftatarsalgia or Morton's Disease, Annals of Surgery. 
September, 1898. 



864 DISLOCATIONS. 

in which excision of the head of the metatarsal bone or of the entire 
joint is occasionally necessary for relief. 

DISLOCATIONS OF THE TOES. 

1. Me tatarso -phalangeal Dislocations. 

Dislocations of the Great Toe. The most common cause is a fall 
upon the toe ; among the less frequent are the act of kicking, receiv- 
ing the weight of the body upon the toe alone in going upstairs, and 
violence recived upon the metatarsus. The injury is frequently com- 
pound. The dislocation has been upward, backward, and to one side, 
the most frequent appearing to be those to the outer side and back- 
ward, and secondly those directly backward ; the former of these two 
is almost always compound, with projection of the head of the meta- 
tarsal bone through the wound on the inner and lower aspect of the 
joint. Coexistent sprain or subluxation of the first tarso-metatarsal 
joint has been occasionally noted. If the lateral displacement is wide 
the flexor tendon may slip past the head of the metatarsal bone and 
make reduction impossible except by operation. 

Of 14 simple cases collated by Delorme reduction was easily made 
in 8 and failed in 4 ; of the compound cases the head of the metatarsal 
bone was excised in 5, and the entire bone removed in 3 ; of 14 com- 
pound cases in which the attempt to reduce was made, it was successful 
in 9. The means employed to reduce have been traction and direct 
pressure upon the base of the phalanx, and arthrotomy in some. 

Dislocations of the Other Toes. Dislocation of the four outer, the 
four inner, or of all five toes together has been reported in several 
cases, the direction of the displacement being upward and backward 
or directly outward ; in the latter the head of the metatarsal projected 
through a wound and had to be excised before reduction could be made. 

2. Dislocations of the Phalanges. 

With one exception, the second phalanx of the third toe, in all the 
cases that have been reported the dislocation was of the terminal pha- 
lanx of the great toe. In one case reduction could not be made ; in 
another, which was compound, a portion of the bone was subsequently 
cast off. 



INDEX TO FKACTUEES. 



A. 

Absorption of bone after fraeture, 

61, 117 
Acetabulum, 320 

floor, 321 

rim, 326 
Acromion, 218 

Age, influence of, on frequency, 20 
Allis, relaxation of fascia lata, 349 
Ambulatory treatment, 106 
Amputation, 112 
Anderson, suture of patella, 389 
Aneurism after fracture of clavicle, 

203 
Apophyses, separation of. 24 
Arrest of growth, 30, 77, 235, 300, 375, 

405 
Arteries, injuries of. 69, 79 
Ashurst & Newell, femur, 352 
Astragalus, 418 

Asymmetry, normal, of limbs, 51 
Atlas, 153 
Atrophy of limb, 78 

interstitial, 39 
Axillary vein, torn, 238 
Axis, 153 

B. 

Bailey, hsematomyelia, 151 
Bardenheuer, traction, 102 
Barker, suture of patella, 391 
Barton's fracture of the radius, 302 
Bennett, first metacarpal, 311 
Bigelow, neck of femur, 330, 340 
Bloodvessels, injury of, 69 
Bolton, hsematomyelia, 150 

neck of femur, 336 
Braun, head of femur, 329 
Buck's extension, 97, 368 
Burrell, fracture of spine, 163 



Calcaneum, 419 

Callender, edge of radius, 303 

forearm, 284 
Callus, exuberant, 62, 74 

formation of, 57 

painful, 75 

retarding influences upon, 116 

softening of, 77 

weak, 77 



Cancer a cause of fracture, 48 
Carpal bones, 306 
Cartilages, fracture of costal, 195 
Causes of fracture, 39 
determining, 40 

muscular action, 41 
predisposing, 39 

acquired tendency, 40 
cancer, 48 

congenital tendency, 40 
disease of nerve-centres, 46 
inherited tendency, 40 
osteomelitis, 49 
rachitis, 47 
syphilis, 47 
Ceci, suture of patella, 393 
Chaput, patellar disability. 393 
Chest, discoloration of skin by com- 
pression of, 193 
Clavicle, 199 

complications, 203, 207 

etiology, 205 

pathology, 199 

relations to dislocation of shoulder, 

570 
simultaneous fracture of both, 20S 
symptoms and course, 206 
treatment, 209 
Clinical course, 64 
Coccyx, 323 
Colles's fracture, 293 
Comminuted fractures. 28 
Complications of fracture, 6S 
early local, 68 
general, 71 
late local, 74 
Compound fractures, 32, 61 

treatment, 109 
Compression fracture, 28 
Condvloid process of inferior maxilla. 

" 172, 173, 179 
Coracoid, 220 

Coronoid process of inferior maxilla. 
172 
of ulna, 278 
Crepitus, 53 
Croux's paste, 96 
Cubitus valgus, 263 

varus, 247, 253. 256. 259 
Cuboid, 423 
Cuneiform, carpal. 310 

865 



866 



INDEX. 



D. 



Dandridge, fracture of spine, 103 
Deformity a symptom, 50 
Delirium, 73 
Depressions, 24 
Diagnosis, 50 
Displacements, 36 
Dressing's, permanent, 95 
temporary, 89 



E. 



Embolism, 78, 120 

fat, 72, 124 
Ensiform appendix, 186 
Epiphysis, separation of, 29 

repair, 63 
Epitroehlea, 257 
Etiology, 39 
Extracapsular, of femur, 331, 337, 344 



Failure of union, 64, 115 
etiology, 116 
treatment, 119 
Femoral artery, torn, 364 

vein, torn, 364 
Femur, 328 

absorption of neck, 343 
angle of neck, 330 
fractures at the lower end, 371 
intercondyloid, 371 
internal epicondyle, 378 
of either condyle, 376 
separation of epiphysis, 374 
at the upper end, 329 

of great trochanter, 361 
of small trochanter, 361 
of the head. 329 
of the neck, 329 
bony union after, 343 
causes, 333 
classification, 332 
diagnosis, 350 
excision of head, 359 
fixation of head, 359 
impaction, 340 
inversion in, 341, 347 
pathology, 334 

through the neck. 334 
at base of neck, 337 
separation of epiphvsis. 
335 
prognosis, 352 
repair, 342 
symptoms, 346 
treatment. 354 
through great trochanter and 
neck. 360 



Femur, fractures of the shaft, 362 
failure of union, 371 
prognosis, 366 
symptoms, 365 
treatment, 367 
in children, 370 
Fenestrated splints, 96 
Fibula, 416 
Fingers, 312 
Fissures, 23 
Fixation, direct, 103 
Foot, 418 
Forearm, 271 

at the elbow, 271 

coronoid process, 278 
head of radius, 280 
neck of radius, 283 
olecranon, 271 
of the shaft, 284 
both bones, 284, 303 
radius, 292 
ulna, 290 
at the wrist, 293 
Colles's, 293 
other than Colles's, 302 
Fractura diacondylica, 256 



G. 



Gangrene, 70 
Glenoid, 223 

Green-stick fractures, 23 
Growth, arrest of, 30, 77, 235, 300. 
375, 405 

exaggeration of, 77 
Gunshot fractures, 33, 112 
Gunstock deformity of elbow, 247, 

254, 256, 259 
Gurlt, statistics, age, 2C 

muscular action, 42 

syphilitic, 47 

tumor, 48 
Gutters, wire, 91 

H. 

HiEMATOMYELIA, 151, 153 

Heart wound in injury of chest, 187, 

191 
Hemorrhage, 69 
Hennequin's splint for arm, 243 

for femur, 357 
Hodgen's splint, 99 
Hudson Street Hospital statistics, 
compound fractures, 33 
general, 19 
humerus, 249, 257 
season, 21 
Humerus, 224 
lower end, 240 

above the condyles, 251 
articular process, 266 
capitellum, 267 



IXDEX. 



867 



Humerus, lower end. development of 
epiphysis. 250, 265 
diagnosis, 269 
epitrochlea, 257 
external condyle, 261 

epicondyle. 258 
intercondyloid fracture. 264 
internal condyle, 250 
separation of epiphysis, 265 
trochlea. 260 
treatment, 270 
shaft. 245 
upper end. 224 

anatomical neck and tuberosi- 
ties, 225 
head, 225 

separation of epiphysis, 232 
surgical neck, 236 
symptoms, 239 
treatment. 241 
tuberosities. 220 
Hutchinson, arrest of g'rowth of leg, 
405 
epiphysis of humerus, 233 
trochanter minor, 361 
Hyoid bone, 180 



Ilium, 324 

Immobilization of joints, 108 
Incomplete fractures, 23 
Inherited tendency to fracture, 40 
Intra-articular fracture, 31 

repair of, 62 
Intra-capsular, of femur, 331, 334, 344 
Intra-uterine. 40 
Ischsemic contraction, 70 
Ischium, 325 



Joints, management of, 107 

stiffness of, 77 
Jugular vein, torn in fracture of cla- 
vicle, 204 



King, neck of femur, 317 
Kingsley, interdental splint, 176 
Kocher, anatomical neck of humerus. 
226 

capitellum, 267 

epiphysis of humerus. 236 

external condyle. 263 

femoral neck.' 332. 360 
upper epiphysis, 336 
Konig, neck of femur, 359 



Lane, fracture of coracoid, 220 

of first rib, 190 
Larynx, 182 
Leg, fractures of, 305 
fibula, 416 
lower end, 403 

by eversion, 405 
by inversion, 413 
comminuted, 403 
anterior portion of tibia. 416 
posterior portion of tibia. 414 
separation of epiphysis of 
fibula, 417 
of tibia, 405 
supramalleolar, 404 
shaft, 309 
upper end, 395 

epiphysis of fibula, 417 

of tibia, 397 
spine of tibia, 397 
tubercle of tibia, 398 
Leucocytosis, 65 
Liability, inherited, 40 
Ligamentum patelle, retraction, 381 
Loew, statistics of prognosis, 125 
Longitudinal fractures, 27 
Lucas-Championniere, massage, 105 
Lumbar puncture in diagnosis, 141 
Lung, hernia of, 193, 196, 540 

injured, in fracture of clavicle, 205 
of ribs, 191 

M. 

Malar bone, 167 
Malgaigne's hooks, 389 
Malgaigne, statistics, age, 20 

femur, 315 

hyoid, 180 

metacarpus, 310 
Marsh, fracture of first rib, 190 
Massage, 105 

Mayor's scarf for clavicle. 211 
Maxilla, inferior, 171 

condyloid process, 172, 173, 179 

coronoid process, 172 

treatment, 174 
superior, 169 
McBurney, epiphysis of femur, 374 
Metacarpal bones, 310 
Metatarsal bones, 423 
Middeldorpf's triangle. 244 
Mobility, abnormal, .">2 
Moulded splints. 03 
Multiple fractures, 31 
Mumford, compound fractures, .'>.*> 
Muscles, atrophy of, 78 

degeneration of, 70 
Muscular action a cause oi fracture, 

41 
Musculo-spiral nerve. 70. 28S, 24S, 254 



868 



INDEX. 



N. 

Necrosis, 61 

Nerve disease a cause of fracture, 46 

inclusion in callus, 76 

injury of, 75, 204 
Nose, 165 



Oblique fractures, 



or, 



26 



Olecranon, 271 
Osteomyelitis, a cause. 49 
Os magnum. 310 



Pain a symptom, 55 

Paralysis a result of fracture. 75 

its effect on repair. 118 
Parkhill's clamp. 104 
Patella. 379 

causes. 379 

course and terminations. 382 

disability after fracture. 3S3. 393 

patholog}-. 380 
- refracture, 385. 394 

symptoms, 382 

treatment, 385 

non-operative. 386 
operative. 390 
Pathological fractures, 45 
Pathologv of fracture, 57 
Pelvis. 314 

acetabulum. 320. 326 

coccyx, 323 

course, 319 

diagnosis. 319 

double vertical fracture. 317 

ilium. 324 

ischium. 325 

lateral portion of ring, 317 

pubic portion of ring. 317 

pubis. 326 

separation in front and behind. 316 
of all three joints. 316 
of pubic symphysis. 315 
of sacro-iliac symphysis. 316 
Periosteal bridge. 38. 58 

fringe. 381, 390 
Periosteum, extent of injury. 57 

share in repair. 58 
Phalanges of hand. 312 
Pisiform. 310 

Plane, double inclined. 101 
Plaster of Paris, 93. 95 
Pneumonia. 73 

Poland, epiphysis of femur. 371 
of fibula. 417 
of humerus. 265 
of tibia. 397 

trochanter. 361 



Pott's fracture at ankle. 405 
Pouteau, fracture of radius, 293 
Prognosis, general. 124 
Pseudarthrosis, 115 

causes, 116 

symptoms, 118 

treatment, 119 
Pubis, 326 

separation of, 315 

R. 

Eachitis. a cause. 47 
Radius, Colles's fracture, 293 

fractures at wrist other than 
Colles's. 302 
longitudinal. 304 
of head, 280 
of neck. 283 
of shaft, 292 
styloid process, 304 
Reduction, 81 
Repair, 57 
of cartilage. 62. 197 
opposing influences, 116 
Retention, 87 
Rheumatism, a cause. 47 
Ribs, 190 

Roberts, fracture of radius, 304 
Robson. suture of patella, 3S9 
Roentgen rays in diagnosis, 54 

s. 

Sacro-iliac synchondrosis, 316 
Sacrum, transverse fracture, 322 

vertical fracture. 317 
Sarcoma after fracture. 75 
Sayre. dressing for clavicle, 212 
Scaphoid, carpal. 307 

tarsal. 422 
Scapula. 215 

acromion. 218 

body. 215 

coracoid process. 220 

glenoid cavity. 223 

inferior angle. 217 

neck. 221 

spine. 218 

upper angle. 218 
Schanz. old. of patella. 394 
Season, influence of. 21 
I Secondarv fracture. 77 
| Semilunar. 309 
Separation of epiphysis. 29 
Septicaemia. 71 
Skin, injury of, 38. 6S 

stained bv compression of chest. 193 
Skull. 127 

mechanism and pathology. 128 

pathological and reparative pro- 
cesses. 136 

symptoms and treatment. 137 



INDEX. 



869 



Skull, symptoms and treatment, 
circumscribed, of vault, 138 
fissured, with brain injury, 140 
internal table, 134, 143 
perforation of base, 14.3 
rupture of middle meningeal. 143 
Smith's anterior splint. 92 
Spine, 147. (See Vertebrae.) 
Spiral fractures, 26 
Splinters, vitality of, 62 
Splints, 89 

long side, 101 
plaster-of-Paris, 93 

suspended, 92 
Spontaneous fractures, 45 
Statistics, compound fractures, 33, 
113 
epiphyses, 29 
general, 19, 125 
influence of age, 20 
season, 21 
syphilis, 47 
tumor, 48 
muscular action, 42 
prognosis, 125 
Sternum, 184 
Stiffness of joints, 77 
Stocking splint, 94 
Stromeyer's cushion, 248 
Subclavian vein, torn in fracture of 

clavicle, 204 
Subjective symptoms, 55 
history, 55 
loss of function, 55 
pain, 55 
Suppuration after fracture, 71 
Supracondyloid of humerus, 251 
Supramalleolar fracture, 404 
Suspended splints, 91 
Sustentaculum tali, 420, 852 
Suture of bones, 103 
Symphysis pubis, separation, 315 
Symptoms, 51 
objective signs, 51 

abnormal mobility, 52 
crepitus, 53 
deformity, 51 
subjective, 55 
Syphilis, a cause, 47 



Tetanus, 73 

Thomas, head of radius, 280 

Thorborn, fracture of spine, 164 

Thrombosis, 69, 78 

Thyroid extract in delayed union. 119 

Tibia, 395. (See Leg.) 

Tibial artery, torn, 400 

Toes, 424 

Trachea, 183 



Traction by suspension, 99, 368 

by weight and pulley, 97 

continuous, 97 

with suspension, 100 
Transverse fractures, 26 
Treatment, 80 

ambulatory, 106 

by amputation, 112 

of compound fractures, 109 
articular, 113 

of gunshot fractures. 112 

of pseudarthrosis, 119 

of vicious union, 120 
Trochanter major, 360, 361 

minor, 361 

u. 

Ulna, coronoid process, 278 
olecranon, 271 
shaft, 290 
styloid process, 304 
Ulnar nerve, injury of. 257 
Union, deformed or faulty, 121 
delayed, or failure of, 115 
fibrous, 115 

V. 

V-shaped fractures, 27 
Varieties, 22 
of direction, 25 
of seat, 29 
Velpeau, dressing for clavicle, 212 
Vertebra?, 147 

course and terminations, 158 
etiology, 151 
pathology, 14S 
arches, 149 
bodies, 148 
eord, 150 
processes, 149 
symptoms, 152 

atlas and axis, 153 
lower cervical and upper dorsal. 
155 
dorsal and upper lumbar. 157 
lumbar, 158 
treatment, 161 
Vertical suspension, 101, 370 
Volkmann's foot-rest, 98 
ischemic contraction. 70 
splint. 90 

suture of patella. 393 
Von Bergmann. of orbital plate, 134 
old fracture of patella. 394 

W. 

Weed's splint. 101 
Whitman, femoral neck, 329, 355 
upper epiphysis. 337 



Z. 



Za'coma. 167 



INDEX TO DISLOCATIONS. 



Accidents during- reduction, 468, 471 
Acetabulum, fracture of edge, 755 

of floor, 784 
Acromion, fracture of, 574, 615 
After-treatment, 469 
Age, influence of, 430 
Ambi, 463 

Anaesthesia, dangers of, 461 
Aneurism after dislocation. 430 
Angot, congenital, 486 
Ankle, congenital dislocations of, 859 

dislocations at or near, 836 
Annandale, recurrent, of jaw, 507 

meniscus, of knee, 813 
Anterior oblique dislocation of hip, 

760 
Arteries injured in dislocation, 438 

in reduction, 468, 473 
Arthrotomy to reduce, 467 
Astragalus, dislocation of, 837 

" total " dislocation of, 850 
Atlas, dislocation of, 526 
Axillary artery, injured in disloca- 
tion, 439 
in reluction, 468, 475 

B. 

Barwell, astragalus, 853 
Bayer, metatarsus, 862 
Bigelow, hip, classification, 747 

reduction, 459, 763, 770 
Bissel-Hagen, congenital, of patella, 

829 
Bloodvessels injured during reduc- 
tion, 473 
in dislocation, 438 
Bone, overgrowth after dislocation, 

449 
Brachial artery, injured in disloca- 
tion, 440 
plexus, torn in reduction, 479 
injured, 616 • 
Brachialis anticus, ossified, 644 
Bradford, congenital, of hip, 495 
Broca, subastragaloid, 843 

suppuration, 483 
Burrell, recurrent, of shoulder, 622 
Busch, obstacles to reduction, 459 



C. 



Cal'caneum, dislocation of, 860 
Caldwell, rupture of circumflex, 474 
Capsule, an obstacle, 460 

lesions of, 436 
Carpal bones, dislocation of, 710. 716 
Carpo-metacarpal dislocations, 721 
Causes, determining, 433 

predisposing", 432 
Cheesman, patella, 828 
Circumflex artery, injured in dislo- 
cation, 439, 475 
nerve, injured in dislocation, 441, 
615 
Clavicle, dislocations of, 544 
acromial end, 552 
subacromial, 558 
subcoracoid, 561 
supra-acromial, 553 
both ends, 561 
sternal end, 544 
backward, 548 
forward, 545 
habitual, 547, 548 
upward, 560 
Coccyx, dislocations of, 737 
Complications (see also Special Dis- 
locations), 437 
of bloodvessels, 438 
of bones, 437 
of nerves, 440 
of soft parts and skin, 443 
of viscera, 443 
Compound dislocations, 443 
Congenital dislocations (see also 
Special Dislocations). 485 
etiology, 486 
pathology at hip, 490 

at shoulder, 493 
statistics, 485 
symptoms, 493 
treatment, 495 
Consecutive reduction. 459 
Coracoid process, fracture of, 615 
Coronoid process of ulna, fracture 

of, (542. 656, (H>.") 
Costal cartilages, dislocations of , 540 
Course, 457 
Cras, injuries of vessels. 47 1 

871 



INDEX. 



Crural nerve, pressed on in disloca- 
tion, 443 
Cuboid, dislocation. S61 
Cuneiform bones, dislocation of, 861 

D. 

Death by anaesthetic, 461, 484 
sudden, after reduction, 484 
Definitions, 427 
Degeneration after dislocation, 443. 

450 
Despres. method of, 465 
Diagnosis, 452 

Distention, dislocation b}\ 500 
Divergent dislocation of radius and 

ulna. 664 
Dollinger, congenital, of hip, 489 
Dorner, radius, with fracture of 

ulna. 686 
Dubreuil, habitual dislocation. 476 
Duchenne, paralytic, of shoulder, 634 
Duverney, radius, by elongation, 681 

E. 

Elastic traction, 466 
Elbow, anatomy of, 635 

dislocations of (sec also Radius 
and Ulna), 635 
backward dislocations, 638 
after-treatment, 648 
complications, 440. 441, 641 
diagnosis, 643 
pathology, 640 
prognosis, 644 
symptoms, 642 
theories of production, 638 
treatment, 645 
classification, 637 
congenital and pathological, 693 
divergent dislocation of radius 

and ulna, 664 
forward dislocations. 659 
fracture during* reduction, 481 
frequency. 637 
injury of nerves in, 441, 642 

of vessels in. 440, 441 
isolated, of radius, 671 

of ulna, 667 
lateral dislocations. 648 
complete outward, 655 
subepicondylar, 658 
supra-epicondylar. 658 
incomplete, 649 
inward, 650 
outward, 652 
old unreduced, treatment. 688 
relations to dislocations of 
shoulder and fracture of 
clavicle. 568 
Embolism, fat. 484 
fatal, 484 



Emphysema during reduction of 

shoulder. 472, 479 
Engel, operation in old, 792 
Ensiform process, dislocation of, 538 
Epitrochlea. fracture of, 640. 654, 662, 

665, 690 
Erecta, luxatio, 598 
Etiology, 432 
Everted dorsal dislocation of hip, 758 



Earabeuf, anatomy of shoulder, 565 
reduction of shoulder, 591 
subtricipital, 589 
thumb, 726 
Fat embolism, 484 
Femoral artery, injured, 440, 785 

vein, injured, 785 
Femur, fracture of head, 755, 786 
of neck, 755, 775. 786 
of shaft, 769, 787 
Fibula, dislocations of, 832 
lower end, 834 
spontaneous and pathological, 

834 
upper end, 832 
Fingers, dislocations of. 726 
distal phalanges, 734 
metacarpo-phalangeal. 732 
of middle phalanges. 733 
Fischer, first metatarsal. 862 
Flaubert, rupture of brachial plexus, 

472, 479 
Flower, classification, shoulder, 570 
Foot, dislocations of, 837 
backward, 837 
compound, 842 
congenital, 837 
forward, 839 
inward, 840 
outward, 841 
upward. 842 
Forearm, avulsion of. 473 
Fracture as a complication, 437 
during reduction, 481 



Gangrene, 446, 482 
Gelle. obstacles to reduction, 459, 763 
Glenoid fossa, fracture of, 615 
Grawitz, congenital, of hip. 489 
Guerin, avulsion of forearm, 473 
Gunn. obstacles to reduction. 459. 763 



Habitual dislocations. 434, 470 
of hip, 790 

of shoulder, 435, 445, 620 
treatment. 470 



INDEX. 



873 



Hamiatomyelia, 151, 153, 514 
Halm, lateral, of elbow, 649 
Harris, operation in old, 792 
Hibon. congenital, of knee, 4S6 
Hip, anatomy of, 740 
dislocations of, 740-796 

accidents in reduction, 789 
after-treatment, 790 
backward dislocations, 750 
anterior oblique, 760 
dorsal, 751 

pathology, 752 
symptoms, 755 
everted dorsal, 758 
treatment, 762 
classification, 746 
complications, 785 
compound, 746 
congenital, 490 
directly upward, 778 
downward and inward, 767 
obturator. 767 
perineal, 772 
on tuberosity of ischium, 782 
fracture during reduction, 789 
of acetabulum, 784 
of femur, 755, 769, 786, 787 
habitual dislocations, 790 
ileo-pectineal, 773 
infracotyloid, 782 
injury of nerves in, 481, 775, 
786 
of vessels in, 440, 785 
intrapelvic, 773 

labrum cartilagineum, detach- 
ment of, 788 
old dislocations, treatment of, 
792 
arthrotomy. 792 
excision, 793 
osteotomy, 793 
paralytic dislocations, 794 
pathological dislocations, 794 
prognosis, 790 

simultaneous, of both hips, 788 
spontaneous dislocations, 794 
statistics, 743 
subspinous, 778 
supracotyloidea, 77S 
suprapubic, 773 
through acetabulum, 320, 783 
upward, 778 

and forward (suprapubic), 773 
Hitzig, metatarsus, 862 
Honigschmied, tibio-tarsal, 837 
Hudson Street Hospital statistics, 

429 
Hueter, outward, elbow, 653 
Humphry, congenital, of radius." 489. 

694 
Hutchinson, suppuration, 482 
vertebrae, 516 



Ileo-pectineal dislocation of hip, 773 
India-rubber, traction by, 466 
Infracotyloid dislocation of hip, 782 
Internal derangement of knee, 812 
Intracoracoid dislocation of shoulder, 

581 
Intrapelvic dislocation of hip, 773 
Irregular dislocations, 46 
Isemeyer, pathological, of patella, 830 



J. 



Jaw, dislocation of lower, 501 

backward, 501 

with fracture, 501 

congenital, 507 

forward, 502 

outward, 502 

pathological, 507 

upward, 502 
Jossel, recurrent, of shoulder, 445 
subglenoid, 597 



Kam merer, fracture of femur, 788 
Knee, dislocations of, 797 
antero-lateral, 808 
backward, 803 
by rotation, 809 
congenital, 486, 815 
forward, 799 
injuries of nerves in, 800 

of vessels in, 439, 778 
lateral, 805 
inward, 808 
outward, 805 
spontaneous and pathological, 

817 
statistics, 798 
internal derangement, 812 
semilunar cartilages, 812 
Kocher on reduction of hip, 764, 771, 
778 
of shoulder, 5S9 
Korte, injuries of vessels, 474 
Kronlein, congenital, 4S5, 486 
statistics, congenital, 486 
elbow, 637 
general, 430 



Labrum cartilagineum, detachment 

of, 788 
Lobker, habitual, of shoulder, 620 

radius, 677 
Lorenz. congenital, of hip. 496 
Lung, hernia of, 193. 196, 540 



874 



IXDEX. 



M. 



Madeltjng, spontaneous, of wrist, 706 
Malgaigne. classification, hip. 747 

shoulder. 569 

radius, with fracture of ulna, 686 
Manipulation, reduction by. 465 

at hip. 762 

at shoulder. 589 
Marchand, accidents in reduction. ' 

462. 474 
Markoe, fracture of humerus, 481 
McBurney's hook. 614 
Mears, old, of shoulder, 627 
Median nerve, injury of, 441. 642 
Medio-carpal dislocations. 710 
Medio-tarsal dislocations, 858 
Metacarpal bones, 721 
Metacarpophalangeal dislocations of 
fingers, 732 

of thumb. 726 
Metatarsal bones, dislocations of, 862 

subluxation of head, 863 
Metatarso-phalano-eal dislocations, 

864 
Midcarpal fracture-dislocation. 712 
Morton, metatarsalgia, 863 
Muscles torn during reduction. 473 
Muscular action a cause of disloca- 
tion, 433 
Musculo-spiral nerve torn, 642, 687 
Myers, congenital, of hip, 495 
Myopathic dislocations, 499 
Myositis ossificans, 644 



N. 



Nerves, injured. 440. 476, 479, 589, 

615. 642, 687. 779 
Newman, patella, 828 
Nicoladoni, old, of elbow, 690 



Obstetrical paralysis. 631 
Obturator dislocation. 767 
Occiput, dislocation of, 519 
(Edema, persistent. 451, 483 
Old dislocations, pathology. 447 

treatment. 467 
Olecranon, fracture of, 641. 660 
Os magnum, dislocation of, 719, 721 



Paci, congenital, of hip. 496 
Faralvsis after dislocation of shoul- 
der, 441. 480, 619 
Paralvtic dislocations, 499 

of hip. 794 

of shoulder. 631 



Patella, dislocations of. 818 

complete reversal. 827 

congenital. 829 

downward with rotation. S28 

edgewise or vertical. 825. s27 

habitual or pathological, 830 

inward. 826 

outward. 821 
Pathological dislocations. 497 
Pathology of old dislocations. 447 

of recent dislocations, 436 
Pelvis, dislocations of, 737 
Pend el-method e. at shoulder. 586 
Perineal dislocations, 772 
Petit, principle of reduction. 464 
Phalanges of foot, dislocations of, 864 
of hand, dislocations of, 726 
distal. 734 
middle, 733 
proximal. 726. 732 
Pingaud. radius, by elongation. 683 
Pisiform, dislocations of. 719 
Poinsot. subastragaloid. 843 
Popliteal artery torn. 439 
Pouteau on reduction of hip. 464 
Prahl. statistics of hip. 743 
Priapism in spinal injuiy, 517 
Prognosis. 457 
Pubic, of hip, 773 



R. 



Padio-carpal dislocations, 699 
backward. 701 
congenital. 709 
forward. 703 
outward. 705 
pathological. 705 
subluxation. 705 
Radio-ulnar joint, lower. 697 
backward. 697 
forward. 698 

inward and downward. 699 
Radius, head broken. 612 
isolated dislocations of. 671 
backward. 672 
by elongation, 681 
forward, 678 
outward, 675 
pathological and congenital, 

489. 493, 693 
with fracture of ulna. 6X6 
Recurrent dislocations, 434 
Reduction, 459 

accidents during, 468, 471 
by manipulation, 465 
consecutive. 459 
methods of, 462 
obstacles to, 459 
spontaneous, 459 
Repair, 444 

Retro-axillary dislocation. 605 
Rheumatism, dislocation in. 498 



INDEX. 



875 



Kibs, broken, 443 

dislocations of, 539 
Eicard, habitual, of shoulder, 470, 623 
Rutherford, patella, 828 

S. 

Scaphoid, dislocations of carpal, 716 

of tarsal, 860 
Schinzinger, reduction of shoulder, 

592 
Schrotter, radius alone, 676, 677 
Sciatic nerve, pressure upon, 755, 786 
Scudder, compound, of foot, 842 

congenital, of shoulder. 626 
Semilunar bone, dislocation of, 717 

cartilages, dislocation of, 812 
Servier, radio-carpal, 700 
Shoulder, anatomy of. 563 
dislocations of, 563-634 
anterior, 573 

after-treatment, 593, 618 

of old, 623 
by muscular action, 434 
intra-coracoid, 581 
subcoracoid, 574 
pathology, 576 
symptoms, 579 
treatment, 5S3 

accidents during, 468, 471 
by manipulation, 589 
Kocher, 589 
Schinzinger, 592 
direct reposition, 585 
heel in axilla, 588 
traction downward, 585 
upward, 5o6 
with leverage, 588 
classification, 56S 
complications, 611 

fracture of acromion, 574, 615 
of coracoid, 610, 615 
of glenoid fossa, 615 
of neck, 612 
of shaft, 615 
of tuberosity, 602, 612 
injury of nerves, 441, 479, 615 
of vessels, 440. 473 
compound dislocations. 617 
congenital dislocations, 493, 627 
downward dislocations, 595 
luxatio erecta. 598 
subglenoid, 595 
subtricipital, 599 
habitual dislocations, 435,445, 620 
injury of nerves in, 441, 479, 615 

of vessels in, 440, 473 
old dislocations, treatment, 624 
arthrotomy, 625 
excision, 626 
fracture, 626 
osteotomy, 627 
subcutaneous section, 625 



Shoulder, dislocations of, paralytic 
dislocations 633 
pathological, 632 
posterior dislocations, 600 
symptoms, 604 
treatment, 605 
prognosis, 618 
recurrent, 435, 445, 620 
relation to other injuries, 568 
retro-axillary, 597 
simultaneous, of both shoulders, 

601, 607, 617 
statistics, 567 
subacromial, 600 
subluxation, 632 
subspinous, 600 
upward (supracoracoid), 606 
Skin torn during reduction, 472 
Smith, Nathan, on manipulation, 465, 

762 
Souchon, old dislocations of shoulder, 

615 
Spinal column (see Vertebrae), 510 
Spontaneous dislocations, 497 

reduction, 459 
Sprengel, lateral, elbow, 649 
Statistics, congenital, 485, 486 
death by anaesthetic, 462 
general, 429, 430 
influence of age, 431 

of paralysis, 441 
injury of vessels, 473, 479 
Sternum, dislocations of body, 534 

of ensiform process, 53S 
Streubel, lateral, elbow, 649 
obstacles to reduction, 459 
patella, 819 
radius alone, 673 
by elongation, 682 
Subacromial dislocation of clavicle, 
558 
of shoulder, 600 
Subastragaloid dislocations, S43 
Subclavicular dislocation of clavicle, 
561 
of shoulder, 574 
Subepicondylar dislocation, 658 
Subglenoid dislocation, 595 
Subscapular artery torn, 473, 47(5. 597 
Subspinous dislocation of hip. 778 

of shoulder, 600, 629 
Subtricipital dislocation, 599 
Suppuration. 462. 483, 789 
Supra-acromial dislocation of clavicle, 

553 
Supracoracoid dislocation of shoul- 
der. 606 
Supracotyloid dislocation of hip. 778 
Supra-epicondylar dislocation. 658 
Suprapubic dislocation. 773 
Sus-cotvloidienne dislocation. 773 
Symptoms, 442 
Syncope, 4S4 



876 



IXDEX. 



Tarsal bones, dislocation of, 860 
Thumb, dislocations of, 726 
backward, 727 
forward, 730 
lateral, 731 

distal phalanx, 734 

proximal phalanx. 726 
Thyroid dislocation. 767 
Tibio-tarsal dislocation, 837 
Tillmanns, lower radio-ulnar, 697 

radio-carpal, 700 
Toes, dislocation of. 864 
Traction by gravity. 467 

elastic, 466 
Trapezium, dislocation of. 720 
Trapezoid, dislocation of, 720 
Treatment, 459 

Trendelburg, old, of elbow. 690 
Tuberosity of humerus, broken. 602. 
603, 612 

u. 

Ulna, fracture with dislocation of 
radius, 686 
isolated dislocation of, 667 
backward. 668 
forward, 671 
inward, 671 
Ulnar artery torn, 441 

nerve injured, 441, 661 
Unciform, dislocation of, 719 

V. 

Vedova, patella, 831 
Verneuil, congenital, 4S8 



Vertebrae, dislocations of, 510 

atlas, 521 

cervical, 523 

classification, 509 

dorsal, 530 

etiology, 515 

lumbar, 532 

occiput, 519 

pathology, 509 

prognosis, 517 

secondary changes. 514 

symptoms, 515 

treatment, 518 
Viscera, injurv to. 443 
Volker, old, of elbow, 690 
Volkmann. pathological, 497 
Voluntary dislocations, 499 
Von Amnion, congenital, 489 

w. 

Warbasse, congenital, of hip. 495 
Wielard, injuries of vessels, 474 
Wippermann, fracture of neck of 

femur, 7S5 
Wrist, dislocations at, 697 
pathological, 705 



Y "LIGAMENT, 741 

ossified, 768 



Y. 



Z. 



Zielewicz, congenital, of patella. 829 



M - -... 1910 







!■■■■■■■■ 



One copy del. to Cat. Div. 



